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RD31  W1 6  1 896         Surgery;  its  theory 


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COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


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SURGERY 


ITS 


THEORY  AND  PRACTICE. 


20,ooo  copies  of  this  book  have  been  sold  during  the  past 
eight  years.  This  fact  is  stated  here  as  being  the  best  evidence 
that  could  be  offered  of  its  usefulness  to,  and  its  popularity 
among,  students  and  physicians. 


SURGERY 


ITS 


THEORY  AND   PRACTICE 


WILLIAM  JOHNSON  WALSHAM, 

F.R.C.S.  Eng.  ;   M.B.  and  CM.  Aberd.  ; 

SENIOR  ASSISTANT-SURGEON,  LECTURER   ON  ANATOMY,  AND    SURGEON   IN   CHARGE 
OF  THE   ORTHOPEDIC   DEPARTMENT,    ST.  BARTHOLOMEW'S    HOSPITAL; 

SURGEON  TO  THE  METROPOLITAN  HOSPITAL;    CONSULTING  SURGEON  TO  THE  HOSPITAL 

FOR  HIP  DISEASES,  SEVENOAKS,  AND  TO  THE  COTTAGE  HOSPITAL,  BROMLEY; 

EXAMINER  IN  ANATOMY  TO  THE  CONJOINT  BOARD  OF  THE  ROYAL  COLLEGE  OF  PHYSICIANS 

AND  ROYAL  COLLEGE  OF  SURGEONS; 

LATE  EXAMINER  IN  SURGERY  TO  THE  SOCIETY  OF  APOTHECARIES. 


FIFTH  EDITION  REVISED  AND  ENLARGED 


THREE  HUNDRED  AND  EIGHTY  ILLUSTRATIONS. 


PHILADELPHIA : 

P.  BLAKISTON,  SON   &   CO., 

IOI2  Walnut  Street. 
1896. 


PREFACE 

TO  FIFTH  EDITION. 


Ix  preparing  a  fifth  edition,  the  Author  has  endeavored  to 
increase  the  usefulness  of  the  work  by  amplifying  those  sub- 
jects that  seemed  to  require  it,  and  by  describing  many  condi- 
tions and  operations  not  mentioned  in  former  editions.  This 
has  been  done  without  materially  enlarging  the  book  by  leaving 
out  such  matter  as,  with  the  advance  of  surgical  science  and 
practice,  has  now  ceased  to  be  of  value. 

The  rapid  sale  (20,000  copies  having  been  printed  in  less 
than  eight  years)  has  encouraged  the  Pubhshers  to  issue  the 
present  edition  in  a  more  convenient  shape  and  size  ;  to  im- 
prove the  character  and  distinctness  of  the  type ;  and  to  lib- 
erally add  to  the  already  numerous  illustrations. 

In  the  work  of  revision  the  Author  has  received  valuable 
help  in  the  pathological  and  bacteriological  sections  from  Dr. 
Kanthack,  Lecturer  on  Pathology,  and  Dr.  DrA-sdale,  Casualty 
Physician,  St.  Bartholomew's  Hospital ;  and  throughout  the  rest 
of  the  book  from  Mr.  W.  G.  Spencer,  Assistant-Surgeon  to  the 
Westminster  Hospital.  He  is  further  indebted  for  many  hints 
and  suggestions  to  Mr.  W.  E.  Miles,  F.R.C.S.,  Dr.  J.  F.  Hall, 
Mr.  E.  L.  Lloyd,  Mr.  W.  Wenmoth  Pryn,  R.  N.,  and  Mr.  Percy 
Furnivall.  He  has  in  addition  to  thank  Mr.  Furnivall  for  his 
kindness  in  reading  the  proof  sheets. 

(V) 


VI  PREFACE. 

Most  of  the  new  illustrations  were  made  from  drawings  by 
Mr.  Prendergast  Parker,  either  from  rough  sketches  by  the 
Author,  or  from  preparations  in  the  Hospital  Museum.  For 
others  the  Author  is  indebted  to  Mr.  Greig  Smith,  Mr.  Paul, 
Dr.  Macintyre,  and  Mr.  Miles. 

77  Harley  Street,  W. 


CONTENTS. 


PAGE 

SECTION  I. 

General  Pathology  of  Surgical  Diseases. 

Inflammation       -------.---17 

Chronic  inflammation       ..-- 33 

Suppuration  and  abscess      ---- 34 

Sinus  and  fistula       ----------  43 

Ulceration  and  ulcers  ----- 44 

Gangrene  or  mortification 51 

Tubercle  and  tuberculosis    ---------58 

Struma  or  scrofula  ----------  63 

Syphilis       ---.--------65 

Haemophilia .         .         .         -^        .  76, 

Tumors       .........---  jy 

Cysts 98 

SECTION  II. 
General  Pathology  of  Injuries. 

Wounds 104 

Contusions  or  bruises 119 

Burns  and  scalds          - 120 

Hremorrhage  -----------  123 

Constitutional  effects  of  injury 136 

Diseases  the  result  of  septic  and  infective  processes  in  wounds  -         -  141 

SECTION  III. 

Injuries  of  Special  Tissues. 

Injuries  of  bones          ----------  168 

Injuries  of  joints      ----------  186 

Injuries  of  muscles  and  tendons  --------  194 

Injuries  of  arteries  ----- 196 

Injuries  of  veins          -...--.---  203 

Injuries  of  nerves   ----------  204 

(vii) 


Vlll  CONTENTS. 

PAGE 

SECTION  IV. 

Diseases  of  Special  T.ssues. 

Diseases  of  bone          -         -         -         -         -         --         -         -         -  209 

Diseases  of  joints    ----------  236 

Diseases  of  muscles     ----------  260 

Diseases  of  tendons         ---...--.  261 

Diseases  of  fascias        - 264 

Diseases  of  bursae    ----------  265 

Diseases  of  arteries,  including  aneurysm       ------  267 

Diseases  of  veins     -         -         -         -         --         -         -         -         -  2P2 

Nsevus         --..-.--.-.-  308 

Diseases  of  lymphatics 310 

Diseases  of  nerves        ----------  314 

Surgical  diseases  of  the  skin 320 

SECTION  V. 

Injuries  of  Regions. 

Injuries  of  the  head 327 

Injuries  of  the  face           ---------  348 

Injuries  of  the  neck,  including  the  entrance  of  foreign   bodies   into   tlie 

pharynx,  oesophagus,  and  air-passages        ------  354 

Injuries  of  the  back         ---------  362 

Injuries  of  the  chest    ----------  3G8 

Injuries  of  the  abdomen           ...-----  376 

Injuries  of  the  pelvis  ----------  394 

Iniuries  of  the  upper  extremity         -------  403 

Injuries  of  the  lower  extremity     --------  429 

SECTION  VI. 

Diseases  of  Regions. 

Diseases  of  the  scalp  and  skull         -------  462 

Diseases  of  the  brain,  calling  for  surgical  interference  -         -         -         -  464 

Diseases  of  the  ear           ---------  468 

Diseases  of  the  eye 482 

Diseases  of  the  lips,  cheeks,  and  mouth 509 

Diseases  of  the  t(jngue         -         -         -         -         -         -         -         -         -518 

Diseases  of  the  uvula,  palate,  fauces,  and  tonsils       -         -         -         -  527 

Diseases  of  the  gums  and  jaws     --------  533 

Diseases  of  the  nose,  naso-pharynx  and  accessory  cavities         -         -  54° 

Diseases  of  the  pharynx  and  fjcsophagus       ------  554 

Diseases  (jf  the  larynx      ---------  560 


CONTENIS.  IX 

PAGE 

Diseases  of  the  parotid  gland       -         -         -         -•'-         -         -         -•  57^ 
Diseases  of  the  thyroid  gland  --------  577 

Diseases  of  the  spine .--.     580 

Surgical  diseases  of  the  intestines     -------  594 

Diseases  of  the  liver,  gall-Vjladder,  stomach,  spleep,  and  pancreas  calling 
for  surgical  interference  -         -         -         -         -         -         -         -         -613 

Hernia 619 

Diseases  of  the  rectum         -         -         -         -         -         -         -         -         -652 

Diseases  of  the  urinary  organs  -------  667 

Diseases  of  the  genital  organs      -         -         -         -         -1-         -         -     728 

Diseases  of  the  female  genital  organs       ------  749 

Diseases  of  the  breast 759 

Deformities  of  the  neck,  knees  and  feet  ------  772 

APPENDIX. 

Amputations --  ""."     7^5 

Index 793 


S/  f»~         ^^^-v^ 


SURGERY: 

ITS  THEORY  AND  PRACTICE. 


SECTION  I. 

GENERAL  PATHOLOGY  OF  SURGICAL  DISEASES. 

INFLAMMATION. 

Infla]\imation  is  defined  by  Dr.  Burdon  Sanderson  as  "  the 
succession  of  changes  which  occurs  in  a  living  tissue  when  it  is 
injured,  provided  that  the  injury  is  not  of  such  a  degree  as  at  once 
to  destroy  its  structure  and  vitaUty."  Inflammation  as  thus  defined 
may  occur  in  any  tissue  of  the  body,  and  in  whatever  tissue  or 
organ  it  occurs,  whether  superficial  or  deep,  transparent  or  opaque, 
vascular  or  non-vascular,  soft  or  hard,  the  pathological  process  is 
essentially  the  same. 

Gexeral  Outline  of  the  Process. — Let  us  first  study  the  pro- 
cess as  it  may  be  observed  by  the  naked  eye,  say,  in  a  portion  of 
inflamed  skin.  The  part  is  uniformly  red,  hotter  than  the  sur- 
rounding skin,  swollen  and  painful.  The  redness  momentarily 
disappears  on  pressure,  and  gradually  fades  away  into  the  natural 
color  of  the  part  around,  but  later  it  becomes  mottled,  and  in 
places  of  a  deeper  hue.  There  is  usually  some  oedema  about  the 
inflamed  spot,  and  the  neighboring  lymphatic  glands  may  be 
slightly  tender  and  enlarged.  If  an  incision  were  now  made  into 
the  inflamed  tissues,  they  would  be  found  fuller  of  blood  than 
natural,  of  a  bright  red  color,  and  infiltrated  with  serum ;  whilst 
if  the  lymphatics  leading  from  the  part  were  opened,  as  has  been 
done  in  animals,  they  would  be  seen  to  be  transmitting  more 
lymph  than  under  normal  conditions.  The  inflammation  may 
now  terminate,  leaving  the  tissues  apparently  normal  {resolution), 
or  it  may  lead  to  certain  changes  producing  irreparable  damage 
I*  07) 


lo  GENERAL   PATHOLOGY   OF   SURGICAL   DISEASES. 

to,  or  total  destruction  of  the  part.  Thus,  the  process  may  be- 
come chronic  and  the  tissues  thickened  and  indurated  {fibroid 
thickening)  :  or  the  tissues  in  the  centre  of  the  inflamed  spot  may 
soften  and  break  down,  forming  a  creamy  fluid  called  pus  (sup- 
puration  and  abscess)  ;  or  the  more  superficial  tissues,  may  un- 
dergo molecular  destruction,  leaving  a  raw  surface  {ulceration^  ; 
whilst  again  the  whole  of  the  tissues  in  the  inflamed  area  may  lose 
their  vitality  and  die  "en  masse"  {gangrene).  When  the  in- 
flammatory process  is  at  all  severe,  constitutional  symptoms  will 
also  be  present.  Thus,  the  temperaiure  will  be  more  or  less 
raised,  the  skin  dry,  the  pulse  increased  in  rapidity,  the  tongue 
furred,  the  appetite  lost,  the  bowels  confined,  and  the  urine  scanty 
and  high-colored — a  condition  known  as  inflammatory  fever,  and 
due  in  almost  every  case  to  the  absorption  of  some  poison  {intox- 
ication). Under  some  circumstances  the  constitutional  symptoms 
may  be  of  a  more  serious  character,  and  secondary  inflammations 
may  be  set  up  in  internal  organs  or  in  other  parts  of  the  body ; 
the  patient  is  then  said  to  be  suffering  from  septic  or  from  infective 
poisoning,  conditions  which,  as  will  be  pointed  out  hereafter,  are 
due  to  poisonous  products  entering  the  general  blood-stream  or 
the  lymph-channels  at  the  primary  seat  of  inflammation. 

The  nmiute  changes  which  occur  in  the  above-described  phe- 
nomena have  of  late  years  been  very  accurately  studied  in  the 
transparent  parts  of  the  mesentery  of  the  frog,  rabbit,  and  dog, 
and  in  sections  of  the  cornea  and  tongue  of  the  frog.  They  are 
divisible  into  (i)  the  changes  occurring  in  the  blood-vessels  and 
their  contents,  and  (2)  the  changes  in  the  fixed  tissue  elements. 
The  following  is  a  brief  summary  of  what  is  observed  : 

I.  Changes  in  the  blood-vessels  and  their  contents. — After,  in 
some  instances,  a  momentary  contraction,  the  vessels  become 
dilated,  the  arteries  first,  and  then  the  capillaries  and  veins,  and 
the  blood  in  them  flows  with  greater  rapidity  {determination  of 
blood  or  actii^e  hyperccmia),  whilst  smaller  vessels  which  were  pre- 
viously invisible  are  now  seen  transmitting  blood.  Hence  the 
redness  of  the  part.  Now,  after  a  longer  or  shorter  period,  ac- 
cording to  the  kind  of  irritant  used  to  set  up  the  inflammation, 
the  blood-current  slackens  at  first  in  the  veins,  and  then  in  the 
capillaries  and  arteries,  and  leucocytes  are  seen  to  drop  out  here 
and  there  from  the  central  stream  or  axial  current,  which  appears 
yellowish  in  color  from  the  red  corpuscles  being  contained  in  it. 
'I'hese  truant  leucocytes  first  roll  lazily  along  in  the  pale  or  cir- 
cumferential current,  and  are  joined  by  more  and  more  as  the 
blood- stream  fiirther  slackens  in  speed.  Now  they  adhere  to  the 
walls  of  the  veins,  and  to  a  less  extent  to  the  walls  of  the  capil- 
laries and  arteries,  so  that  the  vessels  appear  as  if  lined  with  them. 


INFLABIjMATION. 


19 


Soon  they  begin  to  pass  through  the  vessel-walls  into  the  tissues 
around  {diapedesis),  attracted,  according  to  some  writers,  to  the 
seat  of  inflammation  by  the  poison  or  chemical  irritant  which  has 
excited  it  {positive  cheniiotaxis).  By  and  by,  if  the  inflammation 
is  very  acute,  the  colored  corpuscles,  in  groups  of  two  to  a  dozen, 
also  leave  the  central  stream  and  pass  through  the  walls  of  the 
vessels  into  the  tissues,  producing  those  patches  of  darker  redness 
and  the  mottling  of  the  surface  afluded  to  above.  The  central 
stream  next  begins  to  oscillate,  flowing  onwards  during  the  systole, 
and  slightly  receding  during  the  diastole  of  the  heart ;  whilst  the 
colored  corpuscles  show  a  tendency  to  adhere  to  one  another. 
Finally  the  stream  stops,  and  stasis  is  said  to  have  occurred 
(Fig.  I). 

In  the  meantime  the  liquid  contents  of  the  vessels  have  also 
been  passing  through  the  vessel-walls  into  the  tissues,  and  together 
with  the  escaped  leuco- 
cytes, account  for  the 
swelling  and  for  the 
serous  exudation  which 
can  be  squeezed  out 
when-  the  parts  are  cut 
into.  The  serum,  fur- 
ther, soaks  into  the 
neighboring  healthy 
tissues,  thus  explaining 
the  surrounding  oede- 
ma, and  is  thence, 
along  with  some  of  the 
leucocytes,  taken  up  by 
the  lymphatics,  and  so 
passes  back  into  the 
circulation,  and  as  we 
shall  presently  see,  may 
partly  account  for  the 
attendant  inflammatory 
fever.  If  now  the  cause  of  the  inflammation  ceases  to  act,  and 
the  vitality  of  the  tissues  has  not  been  too  much  lowered  to  per- 
mit of  their  recovery,  the  corpuscles  in  the  middle  of  the  stream 
in  those  vessels  where  stasis  has  occurred  again  begin  to  oscillate 
and  then  to  move  on ;  the  leucocytes  no  longer  drop  out  of  the 
axial  current,  and  those  that  have  already  escaped  into  the  tissues 
either  break  down  or  pass  along  with  the  escaped  fluids  into  the 
lymphatics,  leaving  the  part  apparently  uninjured  {?-esotutio?i). 

If  the  above  favorable  termination  does  not    take  place  and 
stasis  is  not  soon  relieved,  coagulation  of  the  serum  rapidly  en- 


Diagram  of  the  minute  changes  in  inflammation. 


20  GENERAL    PATHOLOGY    OF    SURGICAL    DISEASES. 

sues,  and  the  vessels  become  thrombosed.  At  the  same  time, 
moreover,  coagulation  of  the  liquid  exudation  in  the  tissues  also 
occurs.  The  clot  thus  formed  contracts,  squeezing  out  the  serum, 
which  is  then  drained  away  by  the  lymphatics,  so  that  if  the  parts 
at  this  stage  be  cut  into,  a  serous  exudation  will  no  longer  escape. 
The  original  tissues,  partly  in  consequence  of  the  plugging  of  the 
vessels,  and  partly  in  consequence  of  the  digestive  action  of  the 
leucocytes  and  soddening  effect  of  the  fluid  exudation,  become 
swollen  and  softened,  and  finally  lose  their  vitality  and  disappear, 
their  place  being  taken  by  a  mass  of  closely-packed  small  cells 
embedded  in  a  very  slight  amount  of  intercellular  substance. 
This  small-cell-infiltration  was  formerly  thought  to  be  derived 
entirely  from  the  multiplication  of  the  original  tissue  elements. 
More  recently  it  has  been  attributed  to  the  aggregation  of  the 
escaped  leucocytes,  the  tissue  elements  being  beUeved  to  remain 
passive  or  to  undergo  degeneration  ;  whilst  more  recently  still  it 
has  been  ascribed  in  part  to  the  proliferation  of  the  connective- 
tissue  and  other  cells  in  the  inflamed  area,  the  leucocytes,  though 
being  thought  to  play  only  a  subordinate  part  and  sooner  or  later 
to  undergo  disintegration  or  absorption,  forming,  nevertheless,  its 
chief  constituent.  From  whatever  source  these  small  round  cells 
are  derived,  among  them,  especially  during  the  stage  of  repara- 
tion, may  soon  be  seen  numerous  dehcate  capillary  loops,  which 
have  been  formed  from  the  old  capillaries  in  and  around  the  in- 
flamed area,  or  from  the  young  endothelial  or  connective-tissue 
cells.  To  this  vascularized  tissue  the  name  of  inflammatory  new 
formation  or  granulation  tissue  is  given.  When  the  cells  and 
liquid  escape  on  a  free  surface,  the  fibrin  with  the  entangled  cells 
forms  a  so-called  false  membrane. 

2.  Cha?iges  in  the  fixed  elements  of  the  tissues. — When  the  mes- 
entery is  examined  after  inflammation  has  existed  a  short  time, 
the  cells  of  the  origmal  tissue  are  found  to  be  proliferating.  The 
nuclei  of  the  endothelial  cells  divide,  and  the  daughter  cells  thus 
produced  lose  their  endothelial  characters  and  become  pear- 
shaped  and  larger  than  the  escaped  leucocytes  surrounding  them. 
The  connective-tissue  cells  are  believed  to  divide  and  proliferate 
in  like  manner.  Thus,  in  the  earlier  stages  of  inflammation,  two 
kinds  of  cells  may  be  found — a  number  of  small  round  cells,  leu- 
cocytes, which  have  escaped  from  the  vessels,  and  amongst  them 
larger  cells,  which  exhibit  amoeboid  movements  on  a  warm  stage, 
and  are  now  looked  upon  as  being  derived  in  the  way  above 
mentioned  from  the  original  tissue  cells.  These  large  cells  are 
believed  by  many  recent  pathologists  to  continue  to  divide  and 
multiply,  and  to  form  in  chief  parts  the  cells  of  the  inflammatory 
new  formation  or  granulation   tissue.     They   are   called    fibro- 


INFLAMMATION.  2 1 

blasts.  The  escaped  leucocytes  are  supposed,  by  the  supporters 
of  this  view  of  the  formation  of  granulation  tissue,  to  act  the  part 
of  scavengers,  to  eat  up  and  remove  effete  and  dead  tissues,  and 
destroy  in  this  way  any  micro-organisms  that  may  be  present 
{phagocytosis)  and  then  in  their  turn  to  undergo  degeneration 
and  absorption.  By  some  pathologists  the  large  amoeboid  cells 
formed  from  the  connective-tissue  cells  are  believed  to  absorb 
the  leucocytes  which  have  already  done  their  part  in  eating  up 
the  devitalized  tissues  and  micro-organisms,  and  in  addition  to 
aid  in  the  destruction  of  micro-organisms.  The  large  cells  are 
thus  called  macrophages,  the  small  cells  or  leucocytes  microphages. 

Terminations  of  inflammation. — We  have  already  seen  that 
before  coagulation  has  taken  place  and  the  tissues  have  become 
irreparably  damaged,  if  the  cause  of  the  inflammation  ceases  to 
act,  the  process  may  term.inate  and  the  part  resume  its  normal 
condition,  when  resolution  is  said  to  occur.  Faihng  this,  how- 
ever, the  following  terminations  may  ensue.  Thus,  under  favor- 
able circumstances,  the  cells  constituting  the  inflammatory  new 
formation  may  gradually  become  converted  into  fibrous  tissue, 
producing  the  condition  already  referred  to  of  fibroid  thickening 
or  scarring.  Under  less  favorable  circumstances  the  intercellular 
substance  in  the  centre  of  the  mass  of  closely-packed  cells 
liquefies  ;  and  the  cells  are  then  known  as  pus  cells,  whilst  the 
liquefied  tissues  and  exuded  serum  form  a  fluid  {liquor  puris)  in 
which'they  are  contained.  Thus  pus  is  form.ed,  and  suppuration 
is  said  to  be  established.  When  these  changes  occur  on  the  sur- 
face of  the  skin  or  mucous  membrane,  so  that  the  products 
escape  externally,  the  process,  though  essentially  similar  to  that 
of  suppuration,  is  spoken  of  as  ulceration.  And  lastly,  the  in- 
filtrated tissues  in  the  centre  of  the  inflam.ed  area  may  lose  their 
vitality  and  die  en  masse,  before  infiltration  with  leucocytes  and 
serum  has  gone  on  sufficiently  long  to  produce  their  softening ; 
mortification  or  gangrene  is  then  said  to  result. 

Causes  of  inflammation. — The  direct  cause  of  the  inflamma- 
tory phenomena  is  undetermined,  but  is  commonly  supposed  to 
be  due  to  some  change  in  the  vessel-walls  whereby  they  are 
rendered  capable  of  behaving  towards  the  blood  more  or  less  like 
dead  matter,  thus  promoting  a  tendency  to  stasis  and  coagulation 
and  the  escape  of  leucocytes  and  serum  in  abnormal  quantities. 
This  molecular  change  in  the  vessel-walls  may  be  brought  about 
by  some  influence  acting  upon  them,  i,  from  within,  through  the 
blood ;  and  2,  from  without,  either  directly  upon  the  vessel-walls 
themselves,  or  indirectly  through  the  intervention  of  the  con- 
tiguous tissues.  Irritants  acting  in  either  of  these  ways  may  be 
looked   upon  as    exciting   causes,  and   would    appear   in   some 


2  2  GENERAL    PATHOLOGY    OF    SURGICAL   DISEASES. 

instances  to  be  alone  sufficient  to  set  up  the  process.  In  other 
cases,  however,  certain  prior  conditions  such  as  may  be  con- 
sidered to  lower  the  vitahty  of  the  tissues,  and  to  render  them 
less  able  to  resist  deleterious  influences,  appear  necessary  to 
render  such  irritants  operative.  Among  such  predisposing  causes 
may  be  mentioned:  i.  A  deficient  supply  of  healthy  blood 
caused  by  insufficient  or  improper  food  and  air,  a  feeble  action 
of  the  heart,  haemorrhage,  anaemia,  and  the  like.  2.  The  pres- 
ence of  impuriiies  or  of  certain  poisons  in  the  blood,  such  as 
exist  in  chronic  alcoholism,  Bright's  disease,  diabetes,  gout, 
syphilis,  and  in  lead,  mercury  and  phosphorus  poisoning.  3. 
Deprivation  of  healthy  nerve  influence,  as  from  disease  or  injury 
of  a  nerve-centre,  or  nerve-trunk.  4.  Old  age.  5.  The  so-called 
strumous  diathesis. 

The  exciting  causes,  which  are  usually  spoken  of  as  irritants, 
may  be  considered  under  the  following  heads  :  i.  Direct  violence 
and  physical  irritation.  2.  Chemical  irritants.  3.  Micro- 
organisms— saprophytic  and  parasitic.  Micro-organisms,  how- 
ever, most  likely  also  act  by  their  chemical  products. 

1.  Direct  violence  and  physical  irritation. — Under  this  head  are 
included  all  forms  of  mechanical  injury  ;  excessive  heat  or  cold  ; 
electrical  stimulation  ;  the  application  of  strong  acids  or  alkalies, 
or  of  irritating  products,  as  croton-oil  or  mustard ;  friction,  and 
tension.     All  of  these  are  now  admitted  to  be  exciting  causes. 

2.  Chemical  irritants. — The  chemical  products  of  putrefaction 
would  appear  to  play  an  important  part  in  the  causation  of  in- 
flammation. For  fermentation  or  putrefaction  to  occur,  there 
must  be  dead  animal  matter,  a  sufficiency  of  water  and  oxygen, 
the  maintenance  of  a  certain  temperature,  and  the  presence  of  a 
ferment.  This  ferment  consists  of  living  microscopic  organisms, 
species  of  bacteria  known  as  saprophytes,  which  exist  in  large 
numbers  in  the  air,  water,  etc.,  in  short  everyvv^here,  except  per- 
haps in  mid-ocean  and  above  the  snow  line,  and  are  especially 
numerous  in  large  cities,  hospitals,  etc.  It  is  not  thought,  how- 
ever, that  the  inflammation  is  lighted  up  by  the  bacteria  them- 
selves, but  by  the  chemical  products  which  are  formed  in  the 
process  of  fermentation  or  putrefaction,  and  which  soak  into  the 
surrounding  tissues,  acting  like  any  irritant  fluid  or  the  poisonous 
alkaloids.  For  it  has  been  found  that  when  a  fluid  swarming 
with  these  bacteria  {saprophytes)  is  injected  into  the  blood  or 
connective  tissue  of  a  living  animal,  the  bacteria  rapidly  dis- 
apjjear  without  causing  inflammation  or  other  ill-effect.  Again, 
if  a  similar  fluid  is  injected  into  the  peritoneal  cavity  in  such 
quantities  only  as  to  allow  of  its  rajjid  absorption,  no  inflamma- 
tion ensues.     On  the  other  hand,  if  such  a  fluid,  or  even  water,  is 


INFLAMMATION.  23 

injected  in  quantities  more  than  can  be  rapidly  absorbed,  serum 
from  the  blood  is  effused  into  it ;  and  as  all  the  essentials  for 
putrefaction  are  now  present,  viz.,  diluted  serum  which  con- 
stitutes the  dead  animal  matter,  heat,  moisture,  oxygen,  and 
saprophytic  bacteria  to  act  as  a  ferment,  putrefaction  ensues. 
Thus,  to  sum  up,  it  is  inferred  from  these  and  s  milar  experi- 
ments that  the  saprophytic  bacteria  themselves  are  incapable  ^f 
setting  up  inflammation  ;  that  they  are  only  able  to  thrive  in  dead 
animal  matter,  and  not  in  living  tissues ;  and  that  it  is  the  pro- 
ducts of  putrefaction,  of  which  they  are  believed  to  be  the  cause, 
'  that  set  up  the  inflammatory  process. 

3.  Micro-organis7ns. — These,  which  include  the  various  species 
of  micro-organisms,  known  as  pathogenic  or  parasitic  bacteria, 
play  an  important  role  in  the  causation  of  most  inflammations. 
But  whilst  it  cannot  be  admitted  that  they  are  the  exciting  cause 
of  all  inflammations,  the  behef  is  almost  universal  that  they  are 
important,  if  not  the  chief  agents  in  many  inflammations,  and 
especially  in  those  inflammations  which,  because  they  occur  with- 
out any  apparent  cause,  were  formerly  spoken  of  as  idiopathic. 
Thus  erysipelas  and  some  forms  of  osteomyelitis  and  periostitis 
appear  lo  depend  upon  them,  whilst  malignant  pustule  has  been 
proved  to  do  so.  They  are  always  found  in  acute  suppurative 
inflammation.  Unlike  the  saprophytes,  the  bacteria  which  are 
found  in  all  decomposing  fluids,  and  which  as  we  have  seen  are 
unable  to  exist  in  the  living  tissues,  the  parasitic  bacteria  are  not 
only  capable  of  living  in  such  tissues,  but  thrive  and  multiply  in 
them,  and  whilst  doing  so  give  rise  to  certain  irritating  chemical 
products  which  set  up  inflammation.  Hence  their  name,  infective, 
parasitic  or  pathogeiiic  bacteria.  They  not  only  multiply  and 
spread  in  the  surrounding  tissues,  setting  up  inflammation  in  their 
course,  but  also  in  some  instances  enter  the  system  by  the  blood 
or  by  the  lymph-vessels,  where,  still  multiplying,  they  poison  the 
body  generally,  and  in  consequence  of  their  becoming  lodged  in 
the  capillaries  of  various  tissues  or  organs  of  the  body  where  they 
further  multiply  and  thrive,  set  up  there  a  like  inflammation.  The 
way  in  which  they  enter  the  body  is  either  by  a  wound  direct,  or 
else  by  the  alimentary  or  respiratory  mucous  tract.  Where  they 
enter  by  a  wound,  it  appears  that  decomposition  of  the  discharge 
favors  their  entrance  (as  in  erysipelas  occuring  in  a  septic  wound), 
though  such  is  not  essential.  They  or  their  spores  are  supposed 
to  exist  in  the  air,  water,  etc.,  but  in  less  quantities  than  the  sap- 
rophytic bacteria,  and  only  occasionally,  as,  for  instance,  when  a 
case  of  specific  inflammation  to  which  they  give  rise  is  present  in 
the  ward,  etc. 

Many  micro-organisms,  as  already  mentioned,  require  oxygen 


24  GENERAL   PATHOLOGY   OF   SURGICAL   DISEASES. 

of  the  air  for  their  development,  and  are  then  called  aerobic ; 
whilst  others  only  thrive  when  protected  from  access  of  oxygen 
and  are  known  as  anaerobic. 

As  the  various  species  of  bacteria  will  have  to  be  frequently 
mentioned,  they  may  be  here  briefly  described.  The  bacteria 
belong  to  the  group  of  protophytes,  the  simplest  of  vegetable  or- 
ganisms. They  are  divided  into  i,  micrococci  or  spherical 
bacteria ;  2,  bacilli  or  rod-shaped  bacteria  \  and  3,  spirilla  or 
spiral  bacteria.  Micrococci  are  round  or  oval  bodies ;  they  occur 
singly  or  in  pairs.  When  in  pairs  they  are  called  diplococci,  an 
example  of  which  we  find  in  the  gonococcus.  Sometimes  they 
form  chains,  and  are  then  termed  streptococci,  e.g.,  streptococcus 
pyogenes ;  or  they  may  occur  in  grape-like  colonies  (zooglma 
masses'),  and  are  then  spoken  of  as  staphylococci,  the  best  known 
being  the  staphylococcus  pyogenes  aureus.  They  multiply  by 
fission  or  division.  Bacilli  are  rod-shaped  microbes ;  some  of 
them  multiply  by  spores  as  well  as  by  fission.  Hence  a  bacillus 
may  at  one  period  of  its  development  be  rod-shaped,  whilst  at 
another  it  may  be  round  like  a  micrococcus.  The  spores  which 
are  developed  in  the  interior  of  the  bacillus  are  liberated  by  its 
destruction,  and  then  if  the  conditions  are  favorable,  germinate 
and  assume  the  shape  of  the  fully  developed  organism.  The 
spores  have  a  greater  resistance  to  external  influences,  heat  and 
chemicals,  than  the  bacillus  from  which  they  are  formed.  The 
spirilla  are  of  no  surgical  interest,  and  will  not  be  further  men- 
tioned. Both  bacilli  and  micrococci  may  be  divided  into  {a^ 
saprophytic,  and  (/^)  parasitic  bacteria. 

{a)  The  strictly  saprophytic  bacteria  only  live  on  dead  organic 
material  or  in  solutions  of  the  same,  and  are  incapable  of  thriv- 
ing in  the  living  tissues.  Some  species  by  means  of  the  activity 
of  their  protoplasm  not  only  obtain  food  from  the  dead  organic 
material  and  multiply,  but  cause  changes  in  the  fluid  in  contact 
with  their  surface  known  as  fermentation.  To  this  is  due  the  de- 
composition of  serum  or  of  pus  retained  in  a  wound,  the  conver- 
sion of  milk-sugar  into  lactic  acid  in  the  souring  of  milk  in  the 
stomach,  and  the  resolution  of  urea  into  carbonate  of  ammonium 
and  consecjuent  production  of  ammoniacal  urine  in  the  bladder. 
These  micro-organisms  by  their  growth  and  metabolism  elaborate 
substances  either  within  themselves  {intracellular  poisons)  or  in 
the  medium  in  which  they  are  growing,  and  these  substances  act 
as  irritants  to  the  living  tissues,  setting  up  inflammation,  or,  if 
absorbed,  give  rise  to  symjjtoms  somewhat  similar  to  those  pro- 
duced by  the  poisonous  alkaloids. 

The  short  rod-like  body  always  present  in  myriads  in  a  drop  of 
decomposing  fluid  was  formerly  known  as  bacterium  termo,  or 


INFLAMMATION.  2$ 

the  bacterium  of  putrefaction.  More  recently  it  has  been  shown 
that  not  one  but  many  species  of  micro-organisms  were  con- 
founded under  the  term.  Most  of  these  organisms  have  been  but 
imperfectly  investigated  and  are  consequently  still  unnamed. 

Other  bacteria,  instead  of  setting  up  fermentation,  produce  pig- 
ment, as  for  example,  the  bacillus  of  blue  or  green  pus. 

(b)  The  parasitic  bacteria  reside  in  living  organic  material,  and 
derive  their  food  from  the  fluids  of  the  circulation  or  from  the 
protoplasm  of  the  living  cell.  Some  of  these  are  only  capable 
of  thriving  in  living  tissues  {obligatory  parasites)  ;  others,  though 
occasionally  found  in  living  tissues,  are  as  a  rule  found  in  dead 
organic  material  {faciilative  parasites).  Parasitic  bacteria  may 
be  divided  from  a  pathological  point  of  view  into  the  non- 
pathogenic, which  exist  in  the  body  without  doing  any  harm,  and 
the  pathogenic,  which  produce  disease  either  by  their  direct  in- 
fluence or  by  their  chemical  action.  Pathogenic  bacteria  in- 
clude :  I,  those  which  are  capable  of  attacking  a  healthy  though 
susceptible  organism,  as  the  anthrax  bacillus,  and  2,  those  which 
develop  when  the  life  energy  of  the  cells  of  the  organism  is  de- 
pressed, or  when  the  tissues  in  which  they  live  are  altered,  as  the 
tubercle  bacillus.  In  the  former  the  special  properties  of  the 
bacteria,  and  in  the  latter  the  predisposition  of  the  organism  to 
attack,  are  the  determining  factors.  The  methods  by  which 
bacteria  may  gain  admission  to  the  body  and  set  up  inflammation 
have  already  been  referred  to  (p.  23).  Having  gained  admission, 
they  may  merely  affect  the  tissues  at  the  place  of  entry,  setting  up 
a  local  inflammation  ;  or  they  may  extend  by  the  lymphatics  to 
the  nearest  lymphatic  gland,  where  they  may  be  arrested  or  pass 
through  it,  and  thus  enter  the  circulation  ;  or  they  may  make 
their  way  into  the  small  veins,  and  so  gain  the  circulation  at  once, 
and  become  lodged,  according  to  the  nature  of  the  bacteria,  in 
the  capillaries  of  various  tissues  and  organs.  Bacteria  growing  in 
connection  with  a  mucous  membrane  may  extend  along  the  surface 
as  in  diphtheria  \  or  may  be  carried  from  one  point  to  another,  as 
in  phthisis,  from  the  lungs  to  the  larynx  or  intestine.  Diseased 
tissues  produced  by  one  kind  of  bacteria  may  be  secondarily  in- 
fected by  another  kind  ;  thus  the  lung  affected  by  croupous  pneu- 
monia may  sometimes  be  secondarily  infected  by  tubercle  bacilU, 
and  the  tuberculous  tissue  by  the  micrococcus  of  suppuration. 
The  tissues  may  be  protected  against  the  development  of  micro- 
organisms by  the  normal  resistance  of  the  body  to  the  process  of 
disease  {natural  immunity).  Of  acquired  immunity  there  have 
been  several  explanations  offered.  Thus  it  is  believed  that  im- 
munity may  be  brought  about  {a)  by  the  exhaustion  of  the  soil,  /.  e., 
the  occurrence  of  a  disease  once  is  thought  to  protect  against  a 
2 


26  GENERAL   PATHOLOGY   OF   SURGICAL   DISEASES. 

second  attack  through  the  first  disease  having  exhausted  the 
supply  of  the  material  which  is  necessary  for  the  development  of 
the  micro-organism  of  that  particular  disease  ;  {/>)  by  the  chemi- 
cal products  formed  J>ari  passu  with  the  bacteria  acting  as  a 
poison  to  the  bacteria  and  preventing  their  development ;  (r)  by 
certain  chemical  constituents  in  the  blood  serum  which  destroy 
the  bacteria;  {d)  by  the  leucocytes  collecting  around  the 
bacteria,  and  so  killing  them;  and  {e)  by  the  leucocytes  and 
tissue-cells  absorbing  and  destroying  the  bacteria  {phagocytosis). 
Much  has  been  written  of  late  on  the  destruction  of  bacteria  by 
the  leucocytes  and  tissue-cells  { phagocytosis) .  Metschnikoff  and 
his  pupils  hold  that  the  leucocytes  are  endued  with  a  peculiar 
power  of  protecting  the  organism,  that  they  are  attracted  by  the 
bacteria  or  their  products  {chemiotaxis),  gather  round  them,  ab- 
sorb them  into  their  substance,  and  so  digest  or  destroy  them ; 
and  then  that  the  leucocytes  {jnicrophages)  having  thus  performed 
their  function  of  scavengers,  are  in  their  turn  absorbed  by  large 
amceboid  cells  {macrophages)  derived  from  the  tissues,  and  are  in 
like  manner  destroyed.  Other  pathologists  hold  that  the  bacteria 
are  first  killed  or  weakened  by  the  chemical  products  generated 
by  the  bacteria  or  by  the  disinfecting  constituents  in  the  blood- 
serum,  and  then  only  when  dead  or  disabled  are  absorbed  by  the 
leucocytes  and  tissue  cells,  and  along  with  the  devitalized  tissues 
are  in  this  way  got  rid  of. 

Amongst  the  pathogenic  bacteria  of  surgical  interest  may  be 
mentioned  :  the  anthrax  bacillus,  the  cause  of  malignant  pustule ; 
the  tubercle  bacillus  found  in  tubercular  disease ;  the  bacillus  of 
glanders,  of  leprosy,  of  actinomycosis,  of  tetanus,  of  diphtheria, 
and  of  rhinoscleroma  :  the  staphylococcus  pyogenes  aureus  and 
the  streptococcus  pyogenes,  the  organisms  found  in  connection 
with  suppuration ;  the  streptococcus  erysipelatosus  and  the 
micrococcus  gonorrhoeae. 

Signs  and  symptoms  of  inflammation. — These  may  be  divided 
into  the  local  and  constitutional.  The  local  signs  are  the  well- 
known  redness,  heat,  pain  and  swelling,  to  which  may  be  added 
disturbance  or  alteration  of  function.  Except  in  a  typical  case, 
these  signs  aie  not  all  necessarily  present ;  on  the  other  hand, 
the  presence  of  one  or  more  is  not  always  indicative  of  inflamma- 
tion. 

The  redness  is  due  to  the  dilatation  of  the  small  arterioles,  veins 
and  capillaries,  and  increased  flow  of  blood  to  the  part ;  the 
darker  patches  over  the  general  surfiice  to  the  escape  of  red  cor- 
puscles, and  to  the  blood  passing  into  the  veins  before  the 
oxyhemoglobin  has  all  been  reduced.  The  redness  varies  ac- 
cording to  the  intensity  of  the  inflammation,  being  bright  in  the 


INFLAJVIMATlON.  2  7 

acute,  and  dull  in  the  chronic  variety,  and  generally  assumes  a 
livid  hue  when  suppuration  is  about  to  occur.  It  may  sometimes 
be  absent  as  in  inflammation  of  non-vascular  tissues,  although 
present  in  the  vascular  area  around.  It  more  or  less  disappears 
after  death. 

The  increased  heat  is  now  generally  held  to  be  due  merely  to  a 
greater  flow  of  blood  through  the  part,  and  not  to  any  generation 
of  heat  in  the  part  itself,  as  the  blood  coming  from  it  is  never 
hotter  than  the  blood  in  the  left  ventricle  of  the  heart.  The  in- 
flamed part,  however,  feels  intensely  hot  and  burning  to  the 
patient,  although  the  thermometer  shows  httle  actiial  increase  of 
heat. 

The  pain,  which  is  due  to  pressure  upon  or  stretching  of  the 
terminal  nerve-twigs  by  the  dilated  blood-vessels  and  by  the  exu- 
dation, varies  in  intensity  and  character,  and  is  nearly  always 
increased  by  pressure  and  by  the  dependent  position.  It  is  of  a 
stabbing  character  in  serous  membranes,  aching  in  bone,  throb- 
bing when  pus  is  about  to  form  ;  more  intense  when  occurring  in 
organs  where  but  slight  stretching  can  occur,  as  the  globe  of  the 
eye  or  the  testicle  ;  and  less  intense  in  parts  like  the  axilla,  where 
the  tissues  are  loose.  In  the  eye,  as  well  as  pain,  there  may  be 
flashes  of  light ;  in  the  ear,  noise.  The  pain  is  sometimes  referred 
through  the  nerves  to  other  parts  or  organs. 

The  swelling,  which  is  caused  partly  by  the  increased  quantity  of 
blood  in  the  inflamed  area,  partly  by  the  exudation  of  leucocytes 
and  serum,  and  partly  by  the  proliferation  of  the  original  tissue 
elements,  is,  as  might  be  expected,  greatest  in  lax  tissues,  as  the 
axilla,  and  least  in  the  dense  and  fibrous,  as  bone  or  tendon.  It 
is  always  an  important  sign  in  chronic  inflammation  where  there 
may  be  but  little  redness  or  pain. 

The  disturbance  in  function,  which  practically  always  occurs  in 
an  inflamed  part,  may  be  illustrated  by  the  inabihty  of  an  inflamed 
bladder  to  retain  urine,  or  of  an  inflamed  eye  to  tolerate  light. 

The  constitutional  symptoms  may  be  summed  up  as  those  of 
fever.  There  is  a  rise  of  temperature — often  preceded  by  chilU- 
ness  or  even  a  distinct  rigor,  a  quickened  pulse,  dry  skin,  furred 
tongue,  loss  of  appetite,  constipation,  scanty  and  high-colored 
urine,  headache,  perhaps  delirium,  and  a  general  feeling  of  mal- 
aise. When  the  inflammation  is  slight  there  may  be  no  fever ; 
but  when  it  is  at  all  intense,  or  occurs  in  an  important  part,  the 
fever  is  generally  considerable,  and  in  septic  and  infective  inflam- 
mations is  by  far  the  most  anxious  symptom.  Inflammatory  fever 
has  been  divided  into  the  sthenic,  asthenic,  and  the  irritative  or 
nervous.  In  the  sthenic  the  symptoms  are  acute,  the  temperature 
is  high  (104°  or  105°),  and  the  pulse  full,  strong  and  bounding. 


2  8  GENERAL   PATHOLOGV   OF   SURGICAL   DISEASES. 

In  the  asthenic  the  symptoms  assume  what  is  called  a  typhoid 
character ;  the  temperature  falls,  the  tongue  becomes  brown  and 
dry,  the  lips  and  teeth  are  covered  with  sordes,  and  the  pulse  is 
quick,  soft  and  feeble.  .  In  the  irritative  there  is,  in  addition  to 
either  of  the  above  set  of  symptoms,  delirium,  violent  in  the  one 
case,  or  low  and  muttering  in  others  and  a  general  nervous  state. 

The  cause  of  the  fever  has  been  variously  explained.  In  simple 
inflammation  it  may  be  due:  i,  in  part  to  tissue-change  caused 
by  the  presence  in  the  blood  of  free  fibrin  ferment  (a  substance 
known  to  possess  pyrogenic  or  fever-producing  properties),  which 
is  supposed  to  be  derived  from  the  escaped  leucocytes  and  drained 
away  in  the  serum  from  the  inflamed  part  by  the  lymphatics  ;  and, 
2,  in  part  to  disturbance  of  the  heat-regulating  centre  in  the  brain, 
induced  either  reflexly,  through  the  sensory  nerves,  as  when  there 
is  much  pain  and  tension  in  the  inflamed  part,  or  directly,  by  the 
action  on  it  of  the  deteriorated  blood.  In  septic  inflammations 
the  absorption  of  the  products  of  fermentation  or  putrefaction,  as 
from  a  septic  or  ill-drained  wound,  has  no  doubt  a  large  share  in 
the  production  of  the  fever,  which  is  then  spoken  of  as  septic 
{septic  fever,  sap?-cEmia)  ;  whilst  in  the  infective  inflammations  the 
presence  of  micro-organisms  is  beheved  to  be  the  chief  factor  (see 
Septiccemia  and  Pyccmia.') 

Varieties  ok  inflammation. — Inflammation  may  be  divided 
into  the  acute  and  chronic  according  to  its  intensity  and  duration  ; 
the  acute  again  into  the  simple,  the  septic,  and  the  infective.  What 
has  already  been  said  applies  chiefly  to  the  acute  variety.  The 
chronic  is  discussed  separately  later  on. 

Simple  or  traumatic  inflammation  is  that  which  remains  local- 
ized to  a  limited  area,  and  subsides  without  suppuration  as  soon 
as  the  cause  is  removed.  It  is  commonly  the  result  of  a  mechan- 
ical injury,  and  may  be  studied  in  its  simplest  form  in  the  healing 
of  an  incised  wound  by  the  first  intention  (see  Wounds).  Should 
suppuration  occur  it  is  now  generally  held  to  be  due  to  the 
presence  of  certain  pyogenic  micro-organisms  (see  Suppwation, 

p.  38). 

Septic  inflammation  depends  upon  the  presence  of  fermentation 
or  putrefaction  in  a  wound  or  serous  cavity  ;  it  spreads  beyond 
the  original  seat  of  injury,  and  is  accompanied  by  constitutional 
synii)toms  of  blood-jjoisoning  (septic  fever,  saprwrnia).  The 
septic  j)roducts  so'ik  into  the  tissues,  where  they  act  like  other 
chemical  irritants,  and  so  set  up  wider  and  wider  circles  of  inflam- 
mation, and  entering  the  general  blood-stream  with  the  serum 
which  is  drained  away  by  the  lyiiijjhatics,  give  rise  to  septic  poi- 
soning. They  do  not  miilti|)ly  in  the  living  tissues,  like  the  micro- 
organisms producing  the  infective  inflammation  to  be  next  de- 


INFLAMMATION.  29 

scribed.  Hence  as  soon  as  the  fermentation  or  putrefaction  can 
be  checked  the  spreading  of  the  inflammation  and  septic  poison- 
ing have  a  tendency  to  cease.  Septic  inflammation  is  often 
accompanied  by  suppuration,  but  this  is  regarded  as  a  complica- 
tion depending  on  the  presence  of  pyogenic  micro-organisms  (see 
Suppuration) .  Some  pathologists  include  under  the  term  septic 
all  inflammations  attended  by  suppuration  and  the  various  specific 
inflammations,  as  erysipelas,  which  are  here  called  infective. 

The  infective  variety  is  also  of  a  spreading  character,  and  de- 
pends upon  the  presence  of  specific  micro-organisms  {pathogenic 
bacteria) .  Unlike  the  products  of  putrefaction  these  micro- 
organisms multiply  and  thrive  in  the  hving  tissues  and  in  the 
blood-stream.  They  may  also  under  certain  circumstances  be- 
come lodged  in  the  lymphatic  glands  and  in  the  capillaries  of 
distant  tissues  and  organs,  where  they  give  rise  to  inflammations 
similar  to  that  at  the  seat  of  primary  inoculation.  Like  the  septic, 
the  infective  inflammations  are  generally  accompanied  by  severe 
constitutional  symptoms.  The  micro-organisms  may  enter,  it  is 
thought,  either  through  a  wound,  or  through  "the  respiratory  or 
ahmentary  tracts ;  and,  though  not  essential,  a  septic  wound 
favors  their  admission.      (See  Infective  processes  in  woujids.) 

Inflammation  also  admits  of  other  divisions ;  thus  it  is  vari- 
ously spoken  of  as  traumatic,  idiopathic,  strumous,  syphilitic, 
gouty,  &c.,  according  to  its  supposed  cause ;  as  adhesive,  sup- 
purative, and  ulcerative,  according  to  its  termination,  &c. 

The  treatment  of  inflammation  may  be  divided  into  the  Pre- 
ventive and  the  Curative.  The  former  will  be  discussed  under 
the  Treat7nent  of  wounds. 

Curative  treatment. — This  must  necessarily  varj^  according  to 
the  character  and  situation  of  the  inflammation  and  the  type  of 
constitutional  disturbance.  Here  only  are  given  the  indications 
which  should  guide  us  in  the  general  management  of  the  case. 
Our  first  endeavor  where  practicable  should  be  to  remove  the 
cause.  Thus  a  foreign  body  in  the  tissues,  such  as  a  thorn  in  the 
finger,  should  be  extracted ;  tension  should  be  relieved  ;  a  free 
drain  estabHshed  for  any  pent  up  and  decomposing  discharges  ; 
exit  given  to  extravasated  secretions,  as  putrid  urine  and  the  like  ; 
irritating  applications,  as  strong  antiseptics,  exchanged  for  less 
irritating  dressings ;  and  such  constitutional  causes  as  syphihs, 
gout,  &c  ,  treated  by  appropriate  remedies.  When  the  cause 
can  be  thus  removed  and  fresh  sources  of  irritation  avoided,  the 
inflammation  will  tend  of  itself  to  cease.  Where  such  cannot  be 
'  done,  we  should  in  the  second  place  endeavor  to  prevent  the  com- 
plete loss  of  vitality  of  the  already  injured  tissues  and  to  restore 
their  healthy  nutrition.     For  this  purpose  our  efforts  should  be 


30  GENERAL   PATHOLOGY    OF    SURGICAL   DISEASES. 

principally  directed  to  controlling  the  supply  of  blood  to  the 
part,  and  reducing  the  blood-pressure  in  the  damaged  blood-ves- 
sels in  order  to  lessen  the  escape  of  leucocytes  and  serum,  the  pres- 
sure of  which  on  the  vessels  and  tissues  may  lead  to  the  death  of 
the  part,  whilst  the  tension  to  which  they  give  rise  is  a  fertile  source 
of  fresh  irritation  and  consequently  of  the  continuance  of  the  in- 
flammation. Further,  we  should  aim  at  counteracting  this  inju- 
rious pressure  and  tension  by  facilitating  the  draining  away  of  the 
products  of  inflammation  ;  whilst  we  should  seek  to  promote  the 
return  of  healthy  nutrition  to  the  inflamed  tissues  by  endeavoring 
to  remedy  such  constitutional  defects  which,  as  we  have  seen,  by 
lowering  their  vitality  act  as  predisposing  causes.  Thirdly,  we 
should  not  lose  sight  of  the  important  indication  to  relieve  pain. 
And  lastly,  whilst  directing  our  efl"orts  to  the  treatment  of  the 
local  inflammation,  we  must  modify  our  remedies  according  to 
the  type  of  constitutional  disturbance  to  which  it  may  give  rise. 

General  re?nedies. — The  means  at  our  disposal  for  fulfilHng  the 
above  indications  are  both  local  and  constitutional.  In  some 
cases  local  remedies  alone  will  suffice  ;  in  others  constitutional 
remedies  will  also  be  required. 

t  (A)  The  local  may  be  enumerated  as  rest,  elevation  of  the 
part,  cold,  heat  and  moisture,  local  blood-letting,  incisions,  and 
astringents.  These  means  should  not  be  used  indiscriminately  ; 
those  that  may  at  one  period  be  of  the  greatest  benefit,  may  at 
another  produce  the  result  we  are  trying  to  avoid. 

Rest  is  one  of  the  most  important  means  we  possess  in  the 
treatment  of  surgical  inflammation.  It  should  be  complete,  and 
as  far  as  possible  both  functional  and  physiological.  Thus,  an 
inflamed  joint  should  be  placed  on  a  splint,  an  inflamed  eye  re- 
ceive no  light,  etc. 

Elevation  0/  the />art  leWeves  swelling  and  tension  by  diminish- 
ing the  arterial  supply,  and  promoting  venous  return,  and  the 
draining  off"  by  the  lymphatics  of  the  inflammatory  exudation. 
Thus,  an  inflamed  hand  should  be  placed  in  a  sling,  an  inflamed 
foot  raised  on  a  pillow,  etc. 

Cold,  though  a  most  powerful  agent  in  controlling  inflamma- 
tion, is  one  that  requires  cautious  and  seasonable  application.  It 
acts  by  causing  contraction  of  the  small  arteries,  and  conse- 
quently diminishes  the  supply  of  blood  to  the  part ;  it  likewise 
controls  the  amoeboid  movements  of  the  leucocytes.  At  the  same 
time  when  intense  it  lowers  the  vitality  of  the  tissues  and  pro- 
motes adhesion  of  the  corpuscles  and  stasis,  and  as  exemplified 
by  frost-bite  may  destroy  the  part.  It  is  of  the  most  service  in 
the  preventive  treatment  of  inflammation,  and  for  controlling  the 
process  in  the  early   stages.     Later,  when   the  inflammation   is 


INFLAMMATION.  3 1 

fully  established,  it  can  only  do  mischief.  Its  action  should  be 
continuous ;  if  applied  intermittently  it  tends  to  increase  the  in- 
flammation by  the  reaction  which  follows  each  application.  It  is 
best  applied  in  the  form  of  an  ice-bag,  or  by  irrigation  with  ice- 
cold  water,  or  by  Leiter's  tubes. 

Heat  and  moisture  act  by  causing  a  general  dilatation  of  the 
capillaries  and  free  flow  of  blood  through  the  part.  They  are 
especially  useful  when  the  inflammation  has  become  fully  estab- 
Hshed,  and  suppuration  is  threatened.  Under  the  latter  circum- 
stances they  tend  to  localize  the  process,  and  bring  the  abscess 
to  the  surface.  They  may  be  applied  in  the  form  of  boracic  or 
linseed-meal  poultices  or  hot  fermentations  to  which  opium  and 
belladonna  in  some  form  may  be  added  to  soothe  and  reheve 
pain.  The  boracic  poultice  is  made  by  soaking  cotton-wool  or 
lint  in  a  boiling  saturated  solution  of  boric  acid,  or  of  boroglyceride 
(  3j  to  Oj).  The  material  is  then  wrung  out,  applied  to  the  part, 
and  covered  by  gutta  percha  tissue,  or  oil  silk.  Heat  alone  may 
be  applied  by  means  of  Leiter's  tubes,  the  water  being  kept 
heated  by  Krohne's  lamp. 

Loeal  blood-letting  xeWtve?,  the  vessels  of  the  inflamed  part,  and 
so  removes  tension.  It  may  be  employed  in  the  form  of  leeches, 
wet- cupping,  or  incisions  with  a  lancet.  It  is  often  of  great  bene- 
fit, even  when  not  applied  directly  over  the  part,  as  is  shown  by 
the  relief  afforded  to  an  inflamed  eye  by  a  leech  behind  the  ear. 

Incisions  are  useful  in  some  forms  of  inflammation,  as  phleg- 
monous erysipelas,  to  relieve  tension.  They  should  be  made  in 
the  long  axis  of  the  limb,  taking  care  to  avoid  miportant  struc- 
tures. 

Astringents  act  by  constricting  the  blood-vessels,  and  are  espe- 
cially useful  in  inflammations  of  the  mucous  membrane  of  the 
mouth,  nose,  urethra,  and  conjunctiva. 

(B)  Constitutional  remedies,  like  the  local,  should  be  used 
according  to  the  intensity,  nature  and  situation  of  the  inflamma- 
tion, and  the  type  of  the  constitutional  disturbance.  In  an  ordi- 
nary case  of  simple  inflammation,  beyond  a  brisk  purge,  subse- 
quent regulation  of  the  bowels  and  secretions  by  salines,  and  re- 
stricting the  diet,  no  special  constitutional  treatment  is  required. 
But  when  the  fever  is  high,  the  patient  young  and  vigorous,  and 
the  pulse  rapid,  full,  and  strong — in  short,  where  the  fever  is  of 
the  sthenic  type,  antiphlogistic  or  lowering  treatment  should  be 
adopted.  Where,  on  the  other  hand,  the  patient  is  weakly  or 
old,  or  broken  down  in  constitution,  and  the  fever  is  of  a  low  or 
asthenic  type,  a  stimulating  plan  of  treatment  will  be  required. 

Antiphlogistic  treatment  may  be  considered  under  the  heads  of 
diet,  drugs,  and  general  blood-letting. 


GENERAL   PATHOLOGY    OF   SURGICAL   DISEASES. 


The  diet  should  be  restricted  to  milk,  weak  beef-tea,  barley- 
water,  arrow-root,  and  the  like. 

Drugs. — Purgatives  determine  the  flow  of  blood  to  the  intes- 
tines, and  so  relieve  the  inflamed  part.  They  are  not,  however, 
generally  employed,  except  as  a  brisk  purge  at  the  onset  of  the 
inflammation,  and  in  gonorrhoea  and  orchitis,  in  which  they  are 
of  considerable  benefit.  In  inflammations  of  the  intestine  and 
peritoneum  they  should  not  as  a  rule  be  used  at  all.  Diaphoret- 
ics and  diuretics  relieve  the  distended  vessels,  the  former  by 
determining  the  flow  of  the  blood  to  the  skin,  the  latter  to  the 
kidneys.  They  are  not  often  employed  in  surgical  inflammations. 
Aconite  in  small  doses,  frequently  repeated,  is  believed  to  reduce 
the  frequency  and  force  of  the  heart's  action,  and  is  much  praised 
by  some.  Antimony  was  formerly  much  employed,  and  is  still 
used  in  inflamed  testicle.  Mercury,  in  combination  with  opium, 
was  once  in  much  favor,  and  was  thought  to  have  a  controlling 
action  on  the  inflammation.  It  is  seldom  given  at  the  present  day, 
except  in  syphilitic  inflammation,  and  as  a  purgative  at  the  com- 
mencement of  other  inflammations.  Opium,  however,  is  fre- 
quently used  to  relieve  pain,  and  it  also  seems  to  have  some  action 
in  controlling  the  inflammation.  It  may  be  given  by  the  mouth, 
or  in  the  form  of  morphia  as  a  subcutaneous  injection.  Quinine, 
salicylic  acid,  and  antipyrin  are  sometimes  employed  when  the 
temperature  is  high,  as  is  colchicum  in  gout,  potash  and  salicylate 
of  soda  in  rheumatism,  perchloride  of  iron  in  erysipelas,  and 
hyoscyamus,  bromide  of  potassium,  sulphonal,  and  chloral  when 
there  is  want  of  sleep. 

Bleeding  is  not  often  employed  in  modern  surgery,  but  it  is  at 
times  beneficial  in  very  acute  inflammations  in  young  and  pleth- 
oric   subjects.     Of    late 
F'G-  2-  bleeding   has  again  be- 

come not  so  very  uncom- 
mon in  the  medical 
wards.  I'he  surgeon 
should  therefore  make 
himself  acquainted  with 
the  method  of  operat- 
ing. The  blood  may  be 
taken  from  one  of  the 
veins  of  the  arm,  usually 
the  median  basilic,  as 
that  is  the  larger  vessel, 
or  from  the  external  jugular  vein.  In  bleeding  from  a  vein  of  the 
arm  {phlchototny),  a  bandage  or  tape  is  carried  twice  round  the 
arm  a  little  above  the  elbow,  to  obstruct  the  vein,  and  tied  in  a 


Method  of  holding  the  lancet  in  bleeding. 
{Heath's  Minor  .Surgery.) 


CHRONIC    INFLAMMATION.  33 

bow.  Grasping  the  arm  with  the  left  hand,  with  the  thumb  steady- 
ing the  vein,  the  surgeon  makes  an  incision  into  the  vessel,  hold- 
ing the  lancet  with  the  blade  between  his  forefinger  and  thumb, 
about  half  an  inch  from  the  point,  to  prevent  it  penetrating  too 
deeply  (Fig.  2).  The  blood  is  directed  into  a  graduated  bleed- 
ing-bowl, the  flow,  if  necessary,  being  increased  by  the  patient 
making  his  muscle  act  by  grasping  a  stick.  When  sufficient  blood 
has  been  taken  (usually  about  10  oz.)  the  constricting  tape  is 
untied,  a  pad  placed  over  the  incision,  and  the  ends  of  the  tape 
carried  across  the  pad  to  below  the  joint,  then  round  the  arm, 
and  again  over  the  pad,  where  they  are  tied. 

The  stimulating  plan  of  treatment  may  be  considered  under  the 
heads  of  diet,  drugs  and  stimulants.  The  diet  should  consist  of 
essence  of  beef,  milk,  eggs,  milk-puddings,  oysters,  turtle-soup, 
and  of  white  fish  and  minced  chops,  if  solid  food  can  be  retained. 
Of  drugs,  ammonia  and  bark,  or  quinine  and  iron,  will  generally 
be  found  of  most  service ;  whiht  stiniulatits  in  the  form  of 
brandy,  the  brandy-and-egg  mixture,  port-wine,  champagne,  or 
any  other  that  the  patient  has  been  accustomed  to  take,  should  be 
given  in  divided  and  measured  doses  at  stated  intervals.  Stimu- 
lants increase  the  force  of  the  heart's  action,  and  so  drive  the 
blood  through  the  inflamed  part,  and  maintain  the  circulation  till 
the  crisis  has  been  tided  over.  The  indications  for  their  use  are 
a  feeble  and  frequent  pulse,  a  high  temperature,  a  dry  and  brown 
tongue,  and  general  signs  of  prostration. 

CHRONIC    INFLAMMATION. 

The  pathological  process  in  chronic  inflammation  is  essentially 
the  same  as  in  the  acute  ;  but  the  dilated  vessels  appear  to  lose 
their  tone,  and  remain  dilated  for  longer  periods,  and  the  escape 
of  leucocytes  and  proliferation  of  the  original  tissue  elements  are 
continuous.  Further,  the  inflammatory  exudation  contains  less 
fibrin-forming  material  and  albumen.  Like  the  acute,  it  may  ter- 
minate in  resolution,  suppuration  or  ulceration,  but  it  is  much 
more  liable  to  produce  chronic  thickening,  from  the  accumulation 
of  the  cellular  elements  in  the  tissues.  It  may  also  terminate  in 
caseation  or  even  calcification. 

The  causes  of  chronic  inflammation  are  similar  to  those  of  the 
acute,  but  they  appear  to  act  with  less  intensity  and  for  longer 
periods.  Amongst  the  predisposing  causes  must  be  especially 
mentioned  passive  congestion,  struma,  rheumatism,  gout  and 
syphilis.  The  exciting  causes  are  often  very  slight  and  may  be 
altogether  overlooked ;  whilst  secondary  causes  which  may  keep 
up  the  inflammation  for  an  almost  indefinite  time  frequently 
come  into  play.     Thus,  in  chronic  joint-disease,  though  the  cause 


34  GENERAL   PATHOLOGY   OF   SURGICAL   DISEASES. 

may  be  but  a  trivial  injury  in  a  rheumatic  subject,  continual 
movement,  and  tension  due  to  the  distension  of  the  synovial 
membrane,  may  keep  up  the  inflammation  for  months  or  years. 
The  presence  of  miliary  tubercle  is  a  frequent  exciting  cause. 

Sytiiptoms. — These  are  also  local  and  constitutional.  Of  the 
local  signs  the  redness  may  be  absent,  or,  if  present,  may  be  of  a 
dusky  hue,  whilst  the  part  is  often  discolored  from  pigmentation, 
due  to  the  disintegration  of  the  colored  corpuscles.  The  pain  is 
less  severe  than  in  the  acute,  often  of  a  dull  aching  character,  and 
increased  on  pressure,  and  sometimes  worse  at  night.  The  part 
may  be  slightly  hotter  than  natural,  but  at  times  no  increased  heat 
is  apparent.  Swelling  is  always  a  marked  sign.  Constitutional 
symptoms  may  be  altogether  absent ;  generally,  however,  the 
patient's  health  is  feeble  or  below  par,  or  he  is  strumous,  or  he 
has  gouty,  rheumatic,  or  syphilitic  symptoms.  At  times  there 
may  be  some  fever  when  an  important  organ  is  affected. 

Treatment. — The  indications  are  :  to  remove  the  cause  and  all 
secondary  sources  of  irritation ;  to  promote  the  absorption  of  the 
inflammatory  products  ;  and  to  re-establish  the  normal  nutrition 
o^  the  damaged  tissues.  For  this  purpose  constitutional  as  well 
as  local  means  should  be  employed.  Thus,  we  should  endeavor 
to  improve  the  general  health  by  a  careful  dietary  and  the  regula- 
tion of  the  secretions ;  whilst  stimulants  and  tonics  should  be 
given  where  indicated.  In  the  strumous,  cod-liver  oil,  in  the 
syphilitic,  mercury  or  iodide  of  potassium,  in  the  gouty,  colchi- 
cum,  and  in  the  rheumatic,  the  salts  of  potash  or  guaiacum,  are 
especially  indicated;  whilst  residence  at  the  seaside,  or  at  some 
spa  suitable  to  the  diathesis,  or  a  sea  voyage  should  be  enjoined. 
Locally,  the  means  at  our  command,  besides  rest  of  the  part  are  : 
I,  couuter-irritation  by  blisters,  tincture  of  iodine,  and  stimulating 
liniments;  2, friction  with  mercurial  ointment,  the  oleate  of  mer- 
cury or  ointments  of  iodide  of  lead  or  cadmium,  or  by  sham- 
pooing, massage,  etc. ;  3,  pressure  by  means  of  carefully-applied 
bandages,  Scott's  dressing,  or  Martin's  bandage,  or  the  ammonia- 
cum  and  mercury  plaster;  4,  the  formation  oi  sctons  or  issues ; 
and  5,  the  application  of  the  actual  cautery.  Where  suppuration 
threatens,  as  in  chronic  inflammation  of  lymphatic  glands,  sulphide 
of  calcium  may  be  of  service  in  promoting  the  rapid  breaking 
down  of  the  caseating  mass.  It  should  be  given  in  doses  of  ]4, 
to  3/S  of  a  grain. 

SUPPURATION   AND   ABSCESS. 

We  have  already  seen  that  under  some  circumstances  the  in- 
flammatory process  may  terminate  in  the  softening  and  breaking 
down  of  the  inflamed  tissues,  infiltration  of  leucocytes  and  pro- 


SUPPURATION    AND    ABSCESS.  35 

liferation  of  tissue-cells,  and  consequent  formation  of  pus,  sup- 
puration being  then  said  to  be  established.  This  process,  whether 
it  occur  (i)  in  the  substance  of  the  tissues  or  organs,  or  (2)  on 
the  free  surface  of  the  skin,  a  mucous  or  a  serous  membrane,  is 
practically  the  same.  In  the  former  situation,  it  is  spoken  of  as 
circumscribed  or  as  diffuse  suppuration,  according  as  it  is  limited 
in  extent  or  the  reverse  ;  in  the  latter  situation  it  is  known  as 
purulent  exudation  or  catarrh,  or  as  ulceration,  according  as  the 
process  merely  involves  the  superficial  layers  of  the  epithelium, 
or  extends  through  to  the  deeper  parts.  We  will  first  deal  with 
the  circumscribed  variety  of  suppuration  or  abscess,  as  this  is  the 
most  familiar  example  to  surgeons. 

Circumscribed  suppuration  or  abscess. — An  abscess  may  be 
defined  as  a  circumscribed  collection  of  pus,  the  result  of  inflam- 
mation.    It  may  be  acute  or  chronic. 

Acute  abscess. — ^The  formation  of  an  abscess  may  perhaps  best 
be  studied  as  it  occurs  in  the  superficial  tissues.  We  have  al- 
ready seen  that  an  inflamed  part  is  hot,  red,  swollen,  and  painful. 
If  the  inflammation  ends  in  suppuration,  the  swelling  which  was 
more  or  less  diffuse  becomes  circuixiscribed  and  pronounced,  the 
redness  localized  and  more  intense,  the  pain  assumes  a  throbbing 
character,  and  a  distinct  chill  or  rigor  is  generally  experienced. 
On  pressing  lightly  with  the  fingers  on  the  inflamed  part  a  sensa- 
tion of  fluid  beneath  the  skin  is  felt,  and  fluctuation  is  said  to  be 
present.  If  left  to  nature  the  abscess  makes  its  way  in  the  direc- 
tion of  least  resistance,  /.  e.,  generally  towards  the  free  surface  of 
the  skin,  or  if  more  deeply  seated,  towards  a  mucous  canal,  serous 
cavity,  or  the  interior  of  a  joint.  Continuing  to  take  a  superficial 
abscess  as  our  example,  one  part  of  the  inflamed  area  becomes 
more  prominent  than  the  rest,  and  the  skin  over  it  red  and  glazed. 
The  abscess  is  said  to  point.  The  skin  will  shortly  ulcerate  or 
slough,  and  bursting  of  the  abscess  with  discharge  of  the  pus  will 
ensue.  On  the  evacuation  of  the  pus  either  naturally  as  above, 
or  througJi  an  incision  artificially  made,  the  walls  fall  more  or  less 
together,  and  the  cavity  is  gradually  filled  up  by  granulations  till 
finally  only  a  scar  remains.  The  minute  changes  concerned  in 
this  process  are  briefly  as  follows  : — The  leucocytes  which  have 
escaped  from  the  vessels  in  the  way  already  described,  together 
with  the  cells  resulting  from  the  proliferation  of  the  original  tissue 
elements,  aggregate  at  the  focus  of  inflammation  around  the 
micro-organisms,  which,  if  not  already  present  as  the  cause  of  the 
inflammation,  have  now  made  their  way  to  the  inflamed  spot. 
The  tissues,  as  the  result  of  the  devitalizing  action  of  the  products 
of  the  micro-organisms,  undergo  what  is  called  coagulation- 
necrosis,  and  then  softening  and  liquefaction,  and  finally  disap- 


36 


GENERAL   PATHOLOGY    OF   SURGICAL   DISEASES. 


Fig.  3. 


pear  among,  or  are  absorbed  by,  the  leucocytes  and  proliferated 
tissue-cells  which  now  completely  replace  them  in  the  form  of  a 
mass  of  small  round  cells.  Some  of  the  cells  in  the  centre  of  this 
dense  mass  being  cut  off  from  their  nutrient  supply  by  the  destruc- 
tion of  the  vessels,  partly  as  the  result  of  over-stimulation  or  over- 
work in  their  battle  with  the  micro-organisms,  and  partly  as  the 
result  of  the  action  of  the  metabolic  products  of  the  latter,  in 
their  turn  degenerate  and  die,  and  are  now  found  floating  in  a 
fluid  formed  by  the  liquefied  tissues  and  serous  exudation  infiltrat- 
ing the  part.  The  leucocytes  and  proliferated  tissue-cells  are 
known  as  piis-corpiiscles,  the  fluid  as  liquor  puris.  Thus  a  cavity 
is  formed  containing  pus.  Meanwhile  around  the  cavity  the 
leucocytes  and  tissue-cells  continue  to  aggregate  and  thus  form  a 
barrier  to  the  advance  of  the  microbes.  New  vessels  now  grow 
into  the  mass  of  small  round  cells  and  the  abscess-cavity  becomes 
surrounded  by  a  layer  of  vascular  granulation-tissue  {the pyogenic 
zone).     The  accompanying  wood-cut  (Fig.  3)  illustrates  diagram- 

matically  the  appear- 
ance that  would  be 
presented  by  a  section 
through  an  abscess  and 
the  surrounding  tissues. 
In  the  centre  is  the 
abscess-cavity  ;  around 
this  in  the  upper  half  of 
the  diagram  are  zones 
representing  the  inflam- 
matory changes  in  vari- 
ous stages  of  progress. ' 
When  an  abscess  en- 
Jlarges  it  is  simply  by 
the  extension  of  the 
inflammatory  proces-s 
from  zone  to  zone.  The 
central  cavity  (Fig.  3) 
increases  by  the  suc- 
cessive degeneration  of 
the  small  round  cells, 
which  fall  into  the  cavity  and  become  pus-corpuscles,  whilst  what 
was  formerly  the  zone  of  thrombosis  is  now  converted  by  the 
aggregation  of  the  leucocytes  and  proliferated  tissue-cells  into  the 
zone  of  small  round  cells,  the  zone  of  dilated  vessels  and  retarded 
flow  into  the  zone  of  thrombosis,  and  so  on  to  the  circumference. 
Such  at  least  occurs  when  an  abscess  spreads  uniformly  in  all  direc- 
tions.    Usually,  however,  it  makes  its  way  in  the  direction  of  least 


Diagrammatic  representation  of  the  minute  changes  in  the 
formation  and  healing  of  an  abscess.  The  upper  half 
shows  abscess  enlarging;  the  lower  half  abscess  healing. 


SUPPURATION   AND   ABSCESS.  37 

resistance,  these  changes  then  occuring  chiefly  at  that  part.  If 
an  abscess  is  not  opened  the  tension  and  the  presence  of  the  pus 
keep  up  the  inflammation,  but  when  the  pus  is  evacuated  and  all 
sources  of  irritation  are  removed  the  circulation  in  the  vessels 
around  resumes  its  normal  state.  The  walls  in  consequence  of 
the  pressure  of  the  surrounding  tissues  fall  more  or  less  into  con- 
tact, and  what  remains  of  the  cavity  is  gradually  filled  up  by  the 
growth  of  the  granulation-tissue.  The  granulation-tissue  is  de- 
veloped into  fibrous  tissue,  which  in  its  turn  contracts,  obliterating 
the  blood-vessels,  and  is  converted  into  dense  cicatricial  tissue. 
In  the  lower  half  of  the  diagram  (Fig.  3)  are  zones  representing 
the  various  changes  in  the  process  of  healing. 

Character  of  pus. — Pus  from  an  acute  abscess  in  an  otherwise 
healthy  person  is  a  thick,  creamy,  opaque,  yellowish-white,  shghtly 
alkaline  fluid,  with  a  faintish  smell,  saltish  taste,  and  a  specific 
gravity  of  about  1030.  If  a  drop  is  examined  under  the  micro- 
scope it  is  found  to  consist  of  a  fluid  (the  liquor  puris)  and  cor- 
puscles (pus-cells).  Some  of  these  corpuscles  are  globular, 
slightly  granular,  and  measure  uAtj  of  an  inch  in  diameter,  whilst 
some  contain  two  or  three  nuclei  which  are  made  more  evident 
on  the  addition  of  acetic  acid  to  clear  up  the  granular  matter. 
Amongst  them  may  be  seen  other  corpuscles  indistinguishable 
from  leucocytes,  and  exhibiting  when  examined  on  a  warm  stage 
amoeboid  movements.  The  latter  are  living  leucocytes  and  tissue- 
cells,  the  former  leucocytes  and  proliferated  tissue-ceUs  which, 
have  undergone  death  and  degeneration.  The  proportion  of  dead 
to  living  pus-cells  varies  with  the  duration  of  the  inflammation. 
The  liquor  puris  consists  of  water,  albumen,  and  salts,  of  which 
•  chloride  of  sodium  is  the  chief.  It  coagulates  on  boiling.  Though 
probably  derived  in  chief  part  from  the  exudation  of  the  serum 
through  the  vessels,  it  differs  from  serum  in  that  it  does  not  coagu- 
late spontaneously.  In  acute  abscesses  the  pus  contains  granular 
material  derived  from  the  rapid  degeneration  of  the  tissues,  and 
various  species  of  micro-organisms,  usually  cocci.  If  allowed  to 
stand  or  to  decompose  in  an  imperfectly  drained  abscess  cavity, 
it  will  be  found  moreover  teeming  with  the  bacteria  of  putre- 
faction. 

Varieties  of  pus. — Pus  is  variously  spoken  of  as  sauious  when 
it  contains  blood,  curdy  when  portions  of  coagulated  fibrin  are 
seen  floating  in  it,  ichorous  when  of  a  watery  consistency,  viuco- 
pus  when  mixed  with  mucus,  and  infective  when  containing  path- 
ogenic micro-organisms.  In  some  instances  it  has  been  observed 
to  have  a  bluish-green  color  (blue  pus),  due  to  the  presence  of 
the  bacillus  pyocyaneus. 

The  Cause  of  inflammation   terminating  in  an  acute  abscess. 


3S 


GENERAL   PATHOLOGY    OF   SURGICAL   DISEASES. 


may  briefly  be  said  to  be  the  presence  of  tlie  pyogenic  micro- 
organisms in  tissues  whose  vitality  has  been  lowered  by  the  per- 
sistent action  of  an  irritant. 

The  micro-organisms  which  appear  to  be  chiefly  concerned  in 
the  process  of  suppuration  are  the  Staphylococcus  pyogenes  aureus 
and  the  Streptococcus  pyogenes. 

The  Staphylococcus  pyogenes  aureus  is  found  in  inflammations 
running  on  to  suppuration  and  abscess,  and  is  always  present 
wherever  necrosis  of  tissue  is  taking  place.  The  organisms  are 
found  gathered  in  grape-like  (Fig.  4)  masses,  and  the  growth  in 
an  artificial  culture  is  commonly  golden-colored,  but  there  are 
varieties  in  which  the  culture  is  white  or  lemon-colored  {staphylo- 
coccus alb  us,  citreus).  These  organisms  occur  in  suppurating 
wounds,  in  pustular  inflammations  of  the  skin,  in  suppuration  in 
bone,  in  suppurating  joints,  in  acute  periostitis  and  osteomyelitis, 
in  purulent  peritonitis  and  in  empyaema  and  other  deep  abscesses. 
They  may  extend  from  a  wound  either  by  the  lymphatics  or  by 
the  veins  and  give  rise  to  metastatic  abscesses  (pyaemia),  or  they 
may  enter  the  system  through  ulcers  of  the  respiratory  or  digestive 
tract.  The  exact  point  of  entry  in  acute  periostitis  and  osteo- 
myehtis,  ulcerative  endocarditis  and  empysema  is  uncertain. 


Fig.  4. 


Fig.  s. 


Staphylococci.   '•'  950. 
(After  Sternberg.) 


Streptococci,  v  1000, 
(After  Sternberg.) 


The  Streptococcus  pyogenes  is  more  especially  found  in  suppura- 
tion attended  by  phlegmonous  or  purulent  tjedema  with  a  tendency 
to  spread.  The  organisms  occur  in  chains  (Fig.  5).  The  sup- 
purations in  which  they  appear  to  be  chiefly  concerned  may  start 
in  a  septic  wound  of  the  skin,  or  the  puerperal  uterus,  or  on  a 
mucous  or  serous  surface  in  contact  with  decomposing  substances. 
The  absorption  of  the  chemical  products  produced  by  these 
organisms  is  very  liable  to  occur,  giving  rise  to  general  septic 


SUPPURATION   AND   ABSCESS.  39 

poisoning  (septicaemia),  or  if  the  micro-organisms  themselves 
also  gain  access  to  the  circulation,  they  may  become  lodged  in 
the  capillaries  and  produce  metastatic  abscesses,  so  that  the  toxic 
symptoms  produced  by  the  absorption  of  the  chemical  products 
may  be  accompained  by  metastatic  {pyemic')  abscesses.  The 
two  foregoing  micro-organisms,  though  the  chief,  are  not  the  only 
ones  associated  with  suppuration  ;  other  forms  of  micrococci  and 
even  of  bacilH  may  also  at  times  be  found  in  pus.  The  Strep- 
tococcus erysipelatosus  and  the  Micrococcus  gonorrhoece.,  which  are 
closely  allied  to  the  Streptococcus  pyogenes,  are  referred  to  under 
Erysipelas  and  Gonorrhoea. 

The  Symptoms  of  an  acute  abscess  are  at  first  those  of  inflamma- 
tion, followed,  whilst  pus  is  forming,  by  a  chill  or  rigor  and  by 
throbbing  pain  in  the  part.  The  pain,  however,  usually  ceases 
when  suppuration  is  fully  established.  The  local  signs,  when  the 
abscess  is  superficial,  are  pointing,  central  softening,  and  when 
about  to  burst,  a  red  and  glazed  appearance  of  the  skin  with  sepa- 
ration of  the  cuticle.  Deep  suppuration  is  often  difficult  to 
detect ;  deep-seated  fluctuation,  oedema,  subcuticular  mottling 
and  tenderness  on  pressure  are  then  the  chief  signs  ;  but  puncture 
with  a  grooved  needle  will  clear  up  any  doubt. 

Treatment. — The  chief  indications  are  to  remove  the  pus  with 
as  little  injury  to  the  tissues  as  possible,  to  ensure  a  sufficient 
drain,  and  to  maintain  the  parts  aseptic.  When  it  is  evident  that 
suppuration  must  ensue,  it  should  be  promoted  by  moist  warmth 
in  the  form  of  a  large  boracic  poultice  sprinkled  with  opium  or 
hot  poppy  fomentations.  As  soon  as  fluctuation  is  detected  the 
abscess  should  be  opened  by  making  a  free  incision  in  the  most 
dependent  part  or  where  it  is  pointing,  of  course  taking  care  to 
avoid  blood-vessels  or  other  important  structures  in  the  neigh- 
borhood. The  pus  should  generally  be  allowed  to  flow  out  of  its 
own  accord.  To  ensured,  thorough  drain,  and  to  prevent  any  ten- 
sion from  re-accumulation,  the  opening  should  be  free  and  a  drain- 
age tube  should  be  inserted.  If  the  abscess  is  large  a  counter 
opening  may  be  necessary,  or  the  abscess-cavity  may  degenerate 
into  a  sinus.  If  the  drainage  is  efficient,  no  harm  will  ensue  if  a 
poultice,  the  favorite  treatment  of  the  older  surgeons,  be  applied. 
But  if  the  abscess  is  deep  and  the  aperture  small,  and  there  is 
thus  danger  of  the  pus  becoming  retained  and  undergoing  de- 
composition, antiseptic  dressings  or  boracic  fomentations  should 
be  used,  as  under  these  circumstances  the  retained  discharge  will 
probably  be  under  some  degree  of  tension,  and  the  granulation- 
walls  of  the  abscess  hence  inefficient  to  prevent  absorption.  Al- 
though it  is  a  rule  in  Surgeiy  to  open  an  abscess  as  soon  as 
fluctuation  clearly  shows  that  pus  has  formed,  there  are  some  in- 


46  g£ner.\l  path(>logy  of  surgical  diseases. 

stances  in  which  this  is  especially  imperative.  Thus  an  abscess 
should  be  opened  at  once  when  it  is  situated  in  the  perineum,  the 
abdominal  or  thoracic  walls,  the  sheath  of  a  tendon,  under  deep 
fasciffi  or  the  peritoneum,  in  the  orbit,  near  a  joint,  and  in  the 
neck  if  attended  by  dyspnoea  ;  when  obstructing  some  passage  ; 
when  caused  by  the  infiltration  of  urine,  fseces,  &c.,  and  when  a 
spontaneous  opening  would  produce  deformity. 

Hilton's  method,  as  it  is  called,  of  opening  an  abscess,  is  very 
useful  when  the  abscess  is  situated  deeply  and  amongst  important 
structures,  as  at  the  root  of  the  neck  or  in  the  axilla.  It  consists 
in  making  an  incision  through  the  skin  and  fascia,  and  then  work- 
ing gently  in  the  direction  of  the  pus  with  a  director.  As  soon  as 
pus  presents,  a  pair  of  dressing-forceps  is  slid  along  the  groove  of 
the  director  into  the  abscess-cavity,  the  director  removed,  and 
the  blades  of  the  forceps  separated  so  as  to  stretch  the  opening 
and  make  a  free  exit  for  the  pus. 

The  complicatio7is  of  acute  abscess  are:  i.  Haemorrhage  from 
the  involvement  of  a  large  vessel.  2.  The  implication  of  some 
important  part,  as  the  peritoneal  cavity,  the  interior  of  a  joint, 
(Sec.  3.  Degeneration  into  a  sinus  or  fistula.  4.  Blood-poison- 
ing {saprcEmia,  pycBtnia ) . 

A  chronic  abscess  differs  from  an  acute  in  that  it  is  formed 
slowly,  is  unattended  by  the  ordinary  signs  of  inflammation,  and 
does  not  necessarily  depend  upon  the  presence  of  the  pyogenic 
micrococci.  The  contents,  moreover,  are  usually  thin  and  curdy, 
not  thick  and  creamy  like  the  pus  from  an  acute  abscess.  In 
some  situations,  however,  as  in  the  chronic  abscess  in  the  sub- 
cutaneous tissue  so  familiar  to  the  surgeon,  the  contents  may 
differ  very  litde  to  the  naked  eye  from  ordinary  pus,  and,  when 
the  result  of  tubercular  disease,  may  contain  the  tubercle  bacillus. 
A  chronic  abscess  is  generally  formed  in  connection  with  carious 
bone,  joint  disease,  a  caseating  lymphatic  gland,  or  tubercular  de- 
posit. At  times  no  cause  can  be  discovered.  IVheii  due  to  spinal 
caries  a  chronic  abscess  has  a  tendency  to  burrow  in  the  tissues, 
especially  in  the  long  axis  of  the  body  ;  and  its  walls  often  be- 
come condensed  and  thickened,  and  lined  with  a  layer  of  smooth 
granulations,  which  give  it  a  velvety  and  mucous  membrane-like 
appearance,  or  they  may  become  coated  with  a  thick  layer  of 
caseating  tuberculous  matter.  The  symptoms  are  very  various, 
and  differ  according  as  the  abscess  is  found  in  connection  with 
carious  bone,  a  diseased  spine,  &c.,  and  will  be  again  referred  to 
under  the  head  of  Suppuration  in  Bone,  Psoas  Abscess,  &c.  Here 
it  may  be  stated  generally  that  the  chief  signs  are  a  fluctuating 
swelling,  often  unattended  with  any  sign  of  inflammation,  and  the 
presence  of  some  affection,  as  spinal  caries,  that  is  known  to  be 


SUPPURATION    AND    ABSCESS.  4 1 

often  associated  with  abscess.  Before  a  chronic  abscess  is  opened, 
there  are  usually  no  constitutional  symptoms  ;  but  subsequently 
saprophytic  bacteria  or  pyogenic  micrococci  may  gain  admission, 
and  long-continued  suppuration  attended  by  hectic  fever  or 
lardaceous  disease  of  the  viscera  is  very  liable  to  ensue  and 
terminate  fatally  from  exhaustion,  renal  disease,  diarrhoea  or 
hepatic  mischief.  Diagnosis. — A  small  chronic  abscess  in  the 
subcutaneous  tissue  maybe  mistaken  for  a  fatty  tumor,  an  hydatid 
or  other  cyst,  a  blood-extravasation,  or  a  soft  solid  tumor,  and  it 
may  be  quite  impossible  to  arrive  at  a  correct  diagnosis  without 
puncture  with  a  grooved  needle.  The  diagnosis  of  chronic  ab- 
scess connected  with  the  spine,  joints,  &c.,  will  be  further  alluded 
to  in  the  section  on  diseases  of  regions.  Terminatiojis. — A 
chronic  abscess,  after  remaining  quiescent  for  a  long  period,  may 
take  on  increased  action,  and  burst  either  externally,  or  into  a 
mucous  canal,  a  serous  cavity,  &c.,  or  the  watery  portions  of  the 
pus  may  be  absorbed,  leaving  behind  a  caseous  mass,  which  may 
either  dry  up  or  undergo  calcification  ;  or  it  may  remain  in  its 
caseous  state  for  years,  and  then  break  down,  and  set  up  fresh  in- 
flammation around,  and  produce  what  is  called  a  residual  abscess. 
Treatment. — Small  chronic  abscesses  unconnected  with  diseased 
bone,  joints,  &c.,  may  be  freely  incised  and  then  scraped  and 
sewn  up  or  drained  antiseptically.  Large  abscesses,  especially 
when  the  result  of  spinal  disease,  require  very  careful  manage- 
ment. If  free  drtiinage  and  antiseptic  precautions  are  neglected, 
and  the  pus  is  allowed  to  undergo  putrefaction  or  fermentation, 
or  pyogenic  micrococci  gain  admission,  long-continued  suppura- 
tion and  attending, hectic  generally  follow  and  frequently  termi- 
nate fatally.  Hence,  many  advise  that  thi-  opening  of  a  chronic 
abscess  should  be  delayed  as  long  as  posssble — /.  <?.,  until  it  is 
evident  from  the  reddening  of  the  skin,  and  its  near  approach  to 
the  surface,  that  it  will,  if  left  longer,  burst  spontaneously.  The 
objections  to  this  plan  are  that  the  evil  day  is  only  postponed, 
and  that  in  the  meantime  extensive  destruction  of  the  tissues  is 
taking  place  as  the  abscess  is  allowed  to  enlarge.  The  best 
plan  would  appear  to  be  to  aspirate  the  abscess  frequently  so  as 
to  reduce  its  size,  and  then  to  open  it  freely  with  antiseptic 
precautions,  and  ensure  thorough  drainage  subsequently.  As- 
piration alone,  however,  and  especially  when  combined  with  the 
injection  of  iodoform  emulsion,  will  in  some  cases  suffice,  the 
abscess  drying  up,  and  in  this  way  becoming  cured.  When  the 
abscess  is  lined  with  a  thick  layer  of  caseous  material,  heahng 
will  be  promoted  by  rubbing  the  walls  with  a  strong  solution  of 
chloride  of  zirc  (grs.  xl.  to  5J.),  or  by  injecting  iodoform  emul- 
sion (iodoform,  10  parts  ;  glycerine,  70  parts;  water,  20  parts)', 
2* 


42  GENERAL   PATHOLOGY    OF    SURGICAL    DISEASES. 

or  by  scraping  away  the  unhealthy  granulations  with  a  Volk- 
mann's  spoon. 

Diffuse  suppur.'^tion  may  occur  either,  i,  in  the  substance  of 
the  tissues  or  organs ;  or,  2,  on  the  surface  of  the  skin  or  a 
mucous  or  serous  membrane.  As  examples  of  the  former  may 
be  cited  cellular  and  cellulo-cutaneous  er)'sipelas,  in  which  as  the 
result  of  a  spreading  infective  inflammation,  extensive  suppura- 
tion occurs  through  large  tracts  of  the  subcutaneous  tissue ;  as 
examples  of  the  latter,  gonorrhoea,  bronchitis,  and  some  forms  of 
peritonitis.  The  pathological  process  in  both  is  practically 
similar,  only  that  in  one  the  inflammatory  products  (pus)  are 
diffused  through  the  tissues,  and  in  the  other,  over  the  free  sur- 
face. Suppuration  on  the  free  surface  of  the  skin  or  mucous 
membrane  when  the  deeper  layers  of  these  structures  are  involved, 
is,  however,  spoken  of  generally  as  ulceration ;  and  when  the 
epithelial  layers  only  are  affected,  as  intertrigo  in  the  case  of  the 
skin,  and  as  purulent  catarrh  in  the  case  of  a  mucous  membrane. 

Constitutional  effects  of  long-continued  suppuration.  Hectic 
fever  and  lardaceous  disease. — Hectic  fever  is  a  common  ac- 
companiment of  prolonged  suppuration  from  whatever  cause 
when  the  wound  cannot  be  kept  aseptic  and  efficiently  drained. 
It  has  been  ascribed  to  the  drain  on  the  system  owing  to  the  for- 
mation of  large  quantities  of  pus  ;  but  this  is  certainly  not  the 
only  cause,  as  a  chronic  abscess  may  attain  a  very  large  size,  and 
exist  for  years  unattended  by  hectic  as  long  as  it  remains  un- 
opened ;  nor  after  opening  does  hectic  occur  if  the  pus  can  be 
prevented  from  undergoing  fermentative  or  putrefactive  changes, 
and  the  cavity  can  be  well  drained.  It  would  therefore  rather 
appear  to  be  due  to  a  chronic  blood-poisoning,  consequent  upon 
the  absorption  of  the  products  of  fermentation  or  putrefaction  in 
small  quantities  at  a  time.  Symptoms. — Hectic  fever  ia  char- 
acterized by  profuse  sweating,  rapid  wasting,  nocturnal  rises  of 
temperature  with  morning  remissions,  and  generally  by  diarrhoea 
and  deposits  of  urates  in  the  urine.  The  face  is  pale  and 
pinched,  the  cheek  flushed,  the  eye  bright,  the  pupil  dilated,  the 
tongue  red  and  dry  at  the  edges,  and  the  pulse  rapid,  small  and 
weak.  The  appetite  gradually  fails,  the  patient  becomes  weaker 
and  weaker,  and  dies  exhausted  of  diarrhoea,  lardaceous  disease, 
etc.  Treatment. — The  cause  of  the  suppuration  should  be  re- 
moved, or,  if  this  is  impossible,  the  absorption  of  septic  products 
should  be  as  far  as  ])racticable  controlled  by  establishing  a  free 
drain  to  the  suppurating  cavity,  and  by  preventing  by  the  use  of 
antiseptics  the  putrefaction  of  the  discharges.  At  the  same  time 
the  system  must  be  sujtported  by  nourishing  diet  and  stimulants, 
the  sweating  combated  by  dilute  sulphuric  acid  or  atropine,  and 
the  diarrhoea  by  opium,  catechu,  or  other  astringents. 


SINUS   AND    FISTOLA.  43 

Lardaceous  disease  is  another  of  the  complications  that  may 
follow  prolonged  suppuration  consequent  upon  long-standing 
disease  of  the  bones  or  joints.  As  the  disease,  however,  perhaps 
falls  more  often  under  the  notice  of  the  physician  than  of  the 
surgeon,  the  student,  for  a  description  of  it,  is  referred  to  a  work 
on  Medicine. 

sinus  and  fistula. 

When  an  abscess  opens  spontaneously,  or  is  opened  artificially, 
we  have  seen  that  the  cavity  usually  fills  up  with  granulations. 
Under  some  circumstances,  however,  as  when  an  abscess  is  con- 
nected with  dead  bone,  or  contains  a  foreign  body,  or  is  formed 
in  connection  with  a  mucous  canal  or  secreting  gland,  or  its  walls 
after  opening  are  prevented  from  remaining  in  contact  by  mus- 
cular action,  the  abscess  does  not  close,  but  degenerates  into  a 
suppurating  track  called  a  "sinus"  or  "fistula."  Though  the 
terms  "sinus"  and  "fistula  "  are  often  used  synonymously,  the 
former  is  generally  applied  to  such  a  track  when  it  is  only  open 
at  one  end,  the  latter  when  it  is  open  at  both  ends.  Although, 
perhaps,  a  sinus  or  a  fistula  more  often  owes  its  origin  to  the  non- 
closure of  an  abscess,  and  is  hence  described  here,  it  may  also  be 
the  result  of  a  wound,  of  ulceration,  of  sloughing,  or  of  a  con- 
genital defect.  Special  forms  of  fistulge,  as  fistula  in  ano,  recto- 
vesical fistula,  salivary  fistula,  &c.,will  receive  special  notice  under 
Diseases  of  Organs.  Here  generally  it  may  be  said  that  a  sinus, 
and  in  some  instances  a  fistula,  is  a  long  and  often  tortuous  sup- 
purating track,  lined  with  a  smooth  membrane,  and  usually  open- 
ing in  the  midst  of  prominent  granulations.  Treatment. — The 
cause  should  be  sought,  and  if  possible  removed,  and  the  walls  of 
the  sinus  then  pressed  together  by  careful  bandaging.  The 
bandage  should  be  so  applied  as  to  prevent  the  accumulation  of 
pus  in  the  deeper  end,  and  the  consequent  reconversion  of  the 
sinus  into  an  abscess.  If  this  is  found  mipracticable,  a  drainage- 
tube  should  be  inserted  and  shortened  daily  as  the  sinus  gradually 
fills  up  from  the  bottom.  When  the  sinus  has  existed  long,  and 
the  walls  are  callous  and  indurated,  it  should  be  stimulated  by  in- 
jections of  tincture  of  iodine,  nitrate  of  silver,  or  the  like.  Or 
the  lining  membrane  may  be  destroyed  by  chloride  of  zinc,  the 
galvano- cautery  wire,  or  the  benzoline  or  actual  cautery.  These 
and  such  like  means  failing,  the  sinus  should  be  laid  freely  open, 
the  lining  membrane  scraped  away  by  a  Volkmann's  spoon,  and 
the  wound  plugged  with  iodoforni  gauze  or  other  antiseptic 
material  to  ensure  healing  from  the  bottom.  Where  the  laying 
open  of  a  sinus  would  involve  important  structures,  as  a  large 
vessel,  or  necessitate  an  extensive  wound,  or  is  otherwise  imprac- 


44  GENER.'^L   PATHOLOGY   OF   SURGICAL   DISEASES. 

ticable  or  unadvisable,  a  counter-opening  should  be  made  by 
cutting  on  the  end  of  a  long  probe,  and  the  sinus  then  drained  by 
passing  a  drainage-tube  at  first  through  it,  and  subsequently  in  at 
each  end,  and  gradually  withdrawing  the  two  portions  as  the  sinus 
heals.  At  the  same  time  that  these  local  means  are  adopted, 
attention  must  be  paid  to  the  general  health,  as  the  intractabihty 
of  a  sinus  may  depend  in  part,  or  even  entirely,  upon  some  con- 
stitutional derangement.  The  treatment  of  special  fistulge  is  else- 
where described.     {?)tt fistula  in  ano,  etc.) 

ULCERATION   AND   ULCERS. 

Ulceration  is  another  of  the  terminations  of  inflammation, 
and  as  we  have  already  seen,  merely  differs  from  suppuration  in 
that  the  one  occurs  in  the  substance  of  the  tissues,  the  other  on 
the  free  surface.  In  both  there  is  minute  disintegration  and 
liquefaction  of  the  tissues,  with  infiltration  of  leucocytes  and  pro- 
liferation of  tissue-cells  and  degeneration  and  death  of  some  of 
the  infiltrating  leucocytes  and  proliferated  tissue-cells ;  in  sup- 
puration, however,  the  infiltrating  and  proliferating  cells  being 
unable  to  escape  from  an  abscess,  whilst  in  ulceration  the  broken- 
down  tissues  and  pus  are  cast  off  as  soon  as  formed  as  a  discharge 
or  ichor.  An  abscess  may  therefore  be  said  to  be  a  closed  ulcer, 
an  ulcer  an  open  abscess.  This  molecular  death  of  the  tissues 
serves  to  distinguish  ulceration  from  gangrene,  in  which  the 
tissues  die  en  masse  and  are  cast  off  in  the  form  of  a  slough.  The 
two  processes,  however,  are  frequently  combined.  The  softening 
and  breaking  down  of  a  new  growth,  though  not  generally  due  to 
inflammation,  is  also  spoken  of  as  ulceration.  Ulceration  may 
occur  in  any  tissue  of  the  body.  Here,  however,  our  description 
will  chiefly  apply  to  the  process  as  it  affects  the  skin  or  mucous 
membrane.  Let  us  first  study  the  process  as  it  may  be  followed 
with  the  naked  eye  in  a  portion  of  inflamed  skin.  The  cuticle  in 
the  centre  of  the  inflamed  spot  separates  or  is  rubbed  off,  and  a 
raw  surface  is  thus  left  which  gradually  enlarges  in  depth  and  ex- 
tent, leaving  an  angry-looking  sore  exuding  a  sanious  discharge. 
Supposing  the  destructive  process  to  now  cease,  minute  red 
points  called  "granulations"  spring  up  from  the  surface  of  the 
sore,  and  the  discharge  is  replaced  by  ])us.  The  ulcer  skins  over 
from  the  margins,  till  the  raw  surface  is  thus  covered  in,  and 
finally  a  scar  only  is  left  to  mark  the  situation  of  the  former 
wound. 

The  Minute  C/ian_s;es  are  as  follows  : — The  tissues  at  the  focus 
(){  inflammation  where  stasis  has  already  occurred  become  in- 
filtrated with  serum  and  leucocytes  ;  the  cells  of  the  Malpighian 
layer  of  the  epidermis,  of  the  dermis,  and  of  the   subcutaneous 


ULCERATION   AND    ULCERS.  45 

tissue  proliferate ;  the  cells  of  the  cuticle  are  in  consequence 
pushed  forward  before  they  have  had  time  to  assume  their  horny 
character,  and  the  cuticle  thus  softened  readily  separates  or  is 
rubbed  off,  leaving  the  dermis  raw  and  exposed.  The  infiltrated 
and  softened  tissues  forming  the  surface  of  the  sore  become  dis- 
integrated as  in  suppuration,  and  are  cast  off  in  a  m.olecular,  and 
partly  liquid  form,  while  those  a  little  deeper  become  completely 
replaced  by  the  leucocytes  and 
proliferating  cells   which  form    a  ^^^-  ^■ 

layer  of  vascular  granulation-tissue 
(Fig.  6),  essentially  similar  to  that 
forming  an  abscess  wall.  When 
the  cause  of  the  ulceration  is  re- 
moved the  circulation  around  be-  diagram  of  ulreration.  Formation  of 
comes  normal,  the  infiltration  of  granulation-tissue.  New  capillaries grow- 
1  ,  J  J  IT  ina  out   amongst  the  small  round  cells 

leucocytes  and  serum  and  prolif-      from  the  old  capillaries. 
eration  of  the  tissue-cells  cease, 

and  although  the  superficial  cells  of  the  granulation-tissue  at  first 
degenerate  and  are  cast  off  as  pus,  under  healthy  conditions  the 
granulation-tissue  soon  outbalances  in  its  growth  the  superficial 
disintegration  and  thus  fills  up  the  ulcer.  New  epithehum  is 
formed  from  the  old  epithelium  at  the  margin  of  the  ulcer,  and 
gradually  spreads  over  the  surface  of  the  granulations  till  the  ulcer 
is  finally  skinned  over.  The  granulations  develop  into  fibrous 
tissue  which  slowly,  contracts,  helping  to  reduce  the  size  of  the 
wound. 

Causes. — Ulceration,  like  suppuration,  is  due  to  the  action  of 
the  pyogenic  micrococci  or  tissues  weakened  by  previous  inflam- 
mation. For  a  fuller  account  of  the  causes  of  ulceration,  there- 
fore, the  student  is  referred  to  the  causes  of  inflammation  and 
suppuration.  Here  it  may  briefly  be  said  that  the  ulcerations  of 
the  integuments  so  common  in  surgical  practice  are  generally  the 
result  of:  i.  Injury,  often  slight,  inflicted  on  parts  the  vitality  of 
which  is  already  lowered  by  poor  living,  advancing  age  and 
chronic  congestions  due  to  varicose  veins,  long  standing,  &c.  2. 
Certain  morbid  states  of  the  system,  such  as  are  produced  by 
syphilis  and  tubercle.  3.  Pressure,  especially  when  conjoined 
with  a  defective  nerve-supply,  as  an  example  of  which  may  be 
mentioned  bed-sores  occurring  in  cases  of  injury  to  the  spinal 
cord. 

The  treatinc7it  of  ulceration  varies  according  to  the  local  con- 
dition of  the  ulcer  and  the  constitutional  state  of  the  patient,  and 
will  be  discussed  under  Varieties  of  Ulcers.  All  that  need  be  said 
in  general  is,  that  the  cause  should,  if  possible,  be  removed,  all 
sources  of  irritation  avoided,  the  constitutional  state  of  the  patient 


46  GENERAL    PATHOLOGY    OF    SURGICAL    DISEASES. 

treated  with  appropriate  remedies,  and  such  dressings  applied  as 
are  indicated  by  the  local  condition  of  the  ulcer. 

Diseases  of  cicatrices. — After  an  ulcer  has  healed  over  and 
the  granulation-tissue  has  been  converted  into  fibrous  tissue,  this 
latter  continues  to  shrink,  leading  to  obliteration  of  the  blood- 
vessels in  the  cicatrix  and  causing  contraction  and  often  distortion 
of  the  surrounding  parts.  Cicatrices  differ  from  normal  skin  in 
that  they  are  devoid  of  sweat-ducts,  hair-foUicles,  sebaceous  glands 
and  lymphatics,  and  being  also  but  poorly  supplied  with  nerves 
and  vessels,  are  very  apt  to  break  down  on  slight  provocation, 
leading  to  a  re-opening  of  the  ulcer.  Moreover,  owing  to  their 
unstable  nature,  they  are  liable  to  undergo  certain  changes  and 
become  the  seat  of  eczema,  hypertrophy,  keloid,  epithehoma  and 
warty  excrescences,  and  to  be  attended  with  itching,  pain  and 
intense  neuralgia. 

ULCERS, 

An  ulcer  is  the  term  applied  to  an  open  sore  produced  by  a  loss 
of  substance  of  the  free  surface  of  the  skin  or  mucous  membrane 
in  the  process  of  ulceration,  or  of  ulceration  and  gangrene  com- 
bined. The  term,  moreover,  is  sometimes  extended  to  any  open 
granulating  wound  the  result  of  an  injury  or  operation. 

Varieties  of  u/cers. — The  various  names  given  to  ulcers  are 
derived  either  from  their  local  conditions  and  surroundings  or 
from  their  specific  cause.  The  characters  of  the  specific  ulcers, 
however,  often  become  obscured  by  accidental  local  conditions, 
and  these  latter  again  are  constantly  changing  from  day  to  day,  so 
that  an  ulcer  which  at  one  time  would  be  called  callous  may  at 
another  be  in  a  sloughing  state.  The  following  are  examples  of 
the  chief  types  of  ulcers,  but  in  practice  many  minor  shades  of 
difference  in  the  local  appearances  are  met  with,  so  that  it  may  be 
difficult  or  impossible  to  assign  a  given  ulcer  to  a  particular  type. 

A.   U/cers  whose  characters  depend  upon  their  local  condition. 

The  simple,  healthy,  or  healin<^  nicer. — The  edges  are  smooth 
and  shelving,  and  extend  in  the  form  of  a  bluish-white  film  over 
the  marginal  granulations.  The  base  is  level,  or  nearly  so,  and 
covered  with  healthy  granulations.  The  discharge  is  inodorous 
pus,  or  if  the  ulcer  is  dressed  antiseptically,  and  all  irritation 
avoided,  merely  healthy  serum.  The  surrounding  skin  is  healthy. 
This  is  the  type  that  all  ulcers  assume  when  healing.  Treatment. 
— Rest  and  protection  by  any  light  unirritating  dressing  is  all  that 
is  usually  required.  When  large,  cicatrization  may  be  promoted 
by  skin-grafting.     Two  methods  are  employed. 

{a)  Old  method  of  skin-grafting. — Small  pieces  of  healthy  skin, 


ULCERS.  47 

including  the  rete  mucosum  or  actively-growing  epithelial  layer 
but  not  the  whole  thickness  of  the  corium,  should  be  snipped 
from  the  patient's  arm  or  elsewhere  by  the  skin-grafting  scissors 
and  placed  at  once  with  gende  pressure  on  the  granulating  surface 
of  the  ulcer,  and  retained  there  by  suitable  dressings  until  they 
have  become  adherent.  After  a  few  days  the  grafts  often  disap- 
pear, but  this  may  only  be  owing  to  the  loss  of  the  horny  layer  of 
the  epidermis  which  gives  them  their  opacity.  The  active  deeper 
layer  which  is  transparent  may  still  be  there,  and  the  grafts,  if  the 
process  is  successful,  v/ill  become  apparent  in  a  few  days,  as  in 
the  course  of  growth  the  deeper  cells  are  pushed  forward  and 
become  horny.  From  each  islet  of  epithelium  thus  grafted  new 
epithelium  spreads  over  the  surface  of  the  sore.  The  granulating 
surface  of  the  ulcer  must  be  healthy  or  the  grafting  will  not  suc- 
ceed. 

{b)  New  method  of  skin-grafting  (Thiersch's). — The  ulcer 
should  first  be  brought  into  a  healthy  condition,  all  strong  anti- 
septics washed  off  with  boiled  salt  solution  so  that  they  may  not 
come  into  contact  with  the  grafts,  and  the  granulations  scraped 
away.  Longitudinal  shavings  of  skin  should  then  be  taken  from 
the  arm  or  thigh  with  a  sharp  razor,  carried  on  the  razor  to  the 
ulcer,  and  laid  upon  its  surface.  The  grafts  should  overlap  the 
margins  or  they  will,  in  retracting,  leave  a  border  of  granulations. 
There  should  be  no  subcutaneous  tissue  or  fat  on  the  under  sur- 
face of  the  graft ;  indeed  it  is  only  necessary  to  shave  off  the  tops 
of  the  papillfe,  as  the  thinner  the  graft  the  more  easily  it  is 
handled.  The  grafts,  if  prefcired,  may  be  taken  from  an  ampu- 
tated limb,  or  from  a  puppy,  rabbit  or  frog. 

The  exuberant  or  fungous  ulcer  is  generally  due  to  obstructed 
venous  return  from  the  granulations,  the  result  of  undue  contrac- 
tion of  surrounding  tissues,  as  seen,  for  example,  after  a  burn. 
The  edges  are  healthy,  but  the  granulations  rise  up  above  the  sur- 
face, and  are  turgid,  dark  red,  redundant,  and  readily  bleed. 
The  discharge  is  purulent.  Treatment. — Solid  nitrate  of  silver  or 
sulphate  of  copper  should  be  rubbed  over  the  granulations  until 
they  are  reduced  to  healthy  proportions. 

The  ccdematous  or  weak  ulcer  generally  occurs  in  connection 
with  tubercular  bones  or  joints,  but  any  ulcer  may  become  oede- 
matous  if  healing  is  delayed  by  the  too  long  use  of  emollient  ap- 
plications. The  edges  and  surroundings  are  generally  healthy  ; 
and  the  granulations  are  up -raised,  flabby,  bulbous,  semi-translu- 
cent, watery,  and  friable.  The  discharge  is  profuse  and  watery. 
Treatment. — Removal  of  the  cause  where  possible,  uniform  pres- 
sure, and  applications  of  lotions  of  nitrate  of  silver,  or  like 
astringents. 


48  GENERAL   PATHOLOGY   OF   SURGICAL   DISEASES. 

The  inflammatory  and  inflamed  ulcer. ^ — These  terms  are  applied 
to  ulcers  in  which  the  inflammator}'  phenomena  are  the  most 
marked  feature.  The  inflammation  may  depend  on  some  consti- 
tutional disturbance  consequent  upon  alcoholism,  poor  living,  and 
the  like  ;  or  it  may  be  the  result  of  local  irritation  applied  to  any 
ulcer,  whatever  its  previous  character.  For  the  purpose  of  dis- 
tinction, the  term  "  inflammatory  "  is  applied  to  the  former  con- 
dition, whilst  the  term  "inflamed"  is  generally  restricted  to  ulcers 
of  the  latter  class.  Inflammatory  ulcers  have  generally  an  irregu- 
lar shape,  the  edges  are  ragged  and  shreddy,  or  abrupt  or  sharp- 
cut  ;  the  surrounding  skin  is  red  and  oedematous,  and  the  base 
void  of  granulations,  dry,  livid-red,  or  covered  with  a  serous  or 
sanious  discharge  mixed  with  tissue-debris,  and  if  the  inflamma- 
tion is  very  acute,  with  yellow  sloughs.  When  inflammation 
attacks  a  previously  granulating  ulcer,  the  granulations  become 
florid  and  swollen,  and  generally  slough,  whilst  the  surrounding 
parts  present  the  ordinary  inflammatory  phenomena.  The  treat- 
ment should  consist  of  rest,  the  elevation  of  the  part,  the  removal 
of  all  local  irritation,  the  application  of  warm  antiseptic  lotions, 
as  boracic  acid,  on  lint,  attention  to  the  constitutional  state,  and 
regulation  of  the  secretions. 

The  sloughing  ulcer. — This  is  merely  a  severer  degree  of  the 
former,  and  it  differs  from  it  in  that  the  inflammatory  process  is 
more  intense  and  of  a  spreading  character.  It  is  seldom  met 
with  except  in  connection  with  venereal  disease.  The  micro- 
organisms at  work  in  this  and  the  next  form  of  ulcer  are  probably 
only  the  ordinary  pyogenic  micrococci  found  in  all  ulcers,  but 
here  acting  with  greater  intensity  in  a  vitiated  constitution.  The 
ulcer  spreads  with  great  rapidity,  the  edges  are  undermined,  in- 
verted, and  dusky  red,  and  the  base  is  covered  by  an  ash-grey  or 
black  slough.  I'here  is  commonly  much  pain  and  severe  consti- 
tutional fever.  The  treatment  is  similar  to  that  of  the  inflamed 
variety.  Antiseptics  should  be  freely  used  if  the  ulcer  is  foul,  and 
opium  given  if  there  is  much  pain.  When  due  to  syphilis,  the 
proper  remedies  for  that  affection  should,  of  course,  be  given  ; 
but  mercury  should  be  used  cautiously,  or  be  altogether  withheld 
till  the  sloughing  has  ceased. 

The  phagedcEnic  tilcer,  owing  to  improved  sanitation  and 
hygiene,  and  the  more  scientific  treatment  of  wounds,  is  seldom 
seen  at  the  present  day,  except  in  connection  with  venereal 
disease  in  persons  whose  constitution  is  thoroughly  broken  down 
by  intemperance,  poor  living,  and  general  neglect.  The  edges 
of  the  ulcer  are  irregular,  swollen,  and  undermined,  and  the  skin 
around  is  of  a  dark,  ])urplish,  and  dusky-red  color.  The  surface 
is  devoid  of  granulations  and  covered  with  a  dark,  blood-stained 


ULCERS.  49 

ichorous  discharge,  often  mixed  with  sloughs.  When  the  sloughing 
proceeds  to  any  extent,  the  ulceration  is  spoken  of  as  sloughing 
phagedcena.  The  ulcer  spreads  with  fearful  rapidity,  and  often 
destroys  the  whole  organ,  as  the  penis  or  vulva,  and  is  attended 
with  severe  constitutional  disturbance.  Treatment. — The  patient 
should  be  placed  under  an  anaesthetic,  the  surface  of  the  ulcer 
dried,  and  then  thoroughly  destroyed  with  fuming  nitric  acid.  I 
prefer  this  method  myself  as  being  most  efficacious  and  radical 
in  its  action.  Some  surgeons  are  content,  however,  merely  to 
apply  carbolic  acid  (i  in  20)  or  perchloride  of  mercury  (r  in 
1000),  and  then  dust  with  iodoform.  The  continuous  use  of  the 
hot  bath  is  often  of  much  service  in  phagedaena  of  the  penis  and 
vulva.  Internally  opium  should  be  given  in  full  doses,  with 
tonics,  nourishing  diet,  and  when  indicated,  stimulants.  Thorough 
ventilation  and  good  hygiene  generally  are  imperative. 

The  chronic,  callous,  or  indolent  ulcer. — This  condition  of  an 
ulcer  is  the  result  of  continued  irritation  and  neglect,  in  conse- 
quence of  which  the  edges  become  infiltrated  with  inflammatory 
material,  which  impedes  the  circulation  and  prevents  healing.  It 
is  very  common  in  the  lower  third  of  the  leg  in  the  poorer  classes. 
The  edges  are  smooth,  white,  callous,  rounded,  steep,  and  quite 
insensitive  when  touched.  The  skin  around  is  generally  congested 
or  eczeraatous.  The  base  is  covered  with  a  thin  sanious  dis- 
charge, whilst  there  are  either  no  granulations,  or  such  as  are 
present  are  small,  flabby,  pale  and  ill-formed.  These  ulcers  often 
exist  for  years,  and  a*re  usually  attended  with  but  little  pain,  and 
though  they  are  at  times  smaU,  at  other  times  they  extend  nearly 
round  the  leg.  They  are  often  adherent  to  the  fascia,  peri- 
osteum, or  bone.  Old,  callous  ulcers,  when  subjected  to  con- 
tinued irritation,  are  apt,  as  age  advances,  to  become  epithelio- 
matous.  Treatment. — The  callous  edges  should  first  be  softened  by 
emollient  dressings,  and  uniform  pressure  subsequently  applied 
by  a  Martin's  bandage,  or  by  strapping  and  a  bandage.  The 
strapping  plaister,  cut  into  strips  one  and  a  half  inches  wide, 
should  be  evenly  applied  and  extend  two  inches  below  and  the 
like  distance  above  the  ulcer.  Holes  should  be  cut  in  the  strap- 
ping opposite  the  ulcer  to  allow  of  the  escape  of  the  discharge. 
Over  the  strapping  a  bandage  should  be  applied  from  the  foot  to 
the  knee.  The  bandage  should  be  changed  daily  ;  the  strapping 
once  or  twice  a  week.  Iodoform  or  some  other  antiseptic 
powder  should  be  sprinkled  on  the  ulcer  beneath  the  strapping. 
When  the  ulcer  is  very  large  or  extends  quite  round  the  leg  or 
shows  signs  of  becoming  epitheliomatous,  amputation  is  called  for. 

llie  varicose  and  eczemaious  ulcer. — These  terms  are  applied 
to  any  ulcer,  whatever  its  other  characters,  when  associated  re- ' 
3 


50  GENERAL   PATHOLOGY   OF   SURGICAL  DISEASES. 

spectively  with  a  varicose  state  of  the  veins  or  an  eczematous 
condition  of  the  skin.  Both  conditions  frequently  occur  to- 
gether, and  are  described  under  Varicose  Veins. 

The  irritable  or  painful  ulcer. — Though  any  ulcer  may  be  irri- 
table or  painful,  the  above  terms  are  generally  restricted  to  a 
small  painful  ulcer  about  the  anus  (see  Diseases  of  Rectum),  and 
to  a  small,  superficial,  generally  congested  ulcer,  commonly  situ- 
ated about  the  ankle,  and  occurring  chiefly  in  women  beyond 
middle  life.  The  pain  is  often  intense,  and  is  generally  beheved 
to  depend  upon  the  involvement  of  the  nerve-endings.  Treat- 
ment— The  improvement  of  the  general  health,  small  doses  of 
opium,  and  cauterization  with  nitrate  of  silver,  will  often  suffice  to 
cure  the  ulcer.  In  inveterate  cases  an  attempt  may  be  made  to 
divide  the  nerves  subcutaneously  after  the  manner  of  Hilton. 

B.  Ulcers  whose  characters  depend  upo?i  their  specific  origin. 

Tuberculous  or  Strtimous  tilcers  are  generally  due  to  the  break- 
ing down  of  enlarged  tuberculous  lymphatic  glands,  the  bursting 
of  subcutaneous  tuberculous  abscesses,  or  the  ulceration  of  the 
so-called  tuberculous  or  strumous  nodules.  They  are  generally 
multiple,  and  often  confluent,  forming  an  irregular  indolent  sore. 
The  edges  are  pale,  bluish-pink,  thin,  and  undermined.  The 
granulations  are  pale,  cedematous,  protruding,  and  readily  bleed 
when  touched.  The  discharge  is  thin,  yellowish-green  and  scanty. 
Enlarged  glands  and  cicatrices  of  former  ulcers  are  frequently 
present  in  their  near  neighborhood.  The  cicatrices  are  generally 
raised,  pale  pink  or  white,  whilst  the  skin  is  often  puckered-m 
around  them.  Treatment. — Constitutionally  that  for  struma  and 
tubercle.  Locally  the  sore  should  be  destroyed  by  paring  away 
the  edges  and  scraping  the  base  with  a  Volkmann's  spoon.  The 
cicatrices  may  sometimes  be  dispersed  by  repeated  blisterings  or 
by  subcutaneous  division. 

Syphilitic  ulcers. — Primary  ulcers  or  chancres  are  described 
under  syphihs.  Those  occurring  in  the  course  of  constitutional 
syphilis  may  be  divided  into  the  superficial  and  deep,  {a)  The 
superficial  occur  in  the  course  of  pustular  and  tubercular  syphi- 
lides,  and  are  often  associated  with  patches  of  these  eruptions  on 
other  parts  of  the  body.  They  are  usually  circular  or  crescentic 
in  shape,  spreading  by  their  convex  margin,  and  healing  on  their 
concave.  Their  edges  are  sharp-cut,  and  often  surrounded  by  an 
areola  of  dusky  redness  ;  their  base  is  but  slightly  depressed,  and 
of  a  dark  red  color,  and  is  often  covered  by  a  yellow  slough,  or  a 
nipial  or  ecthymatous  scab.  Several  of  these  ulcers  frequently 
coalesce,  giving  rise  to  a  serpiginous  or  annular  form  of  ulcerae 
tion,  which  is  very  characteristic  of  syi)hilis.     (^)  The  deep  ar- 


GANGRENE.  5 1 

due  to  the  breaking  down  of  gummata.  They  are  circular  or  oval 
in  shape  ;  their  edges  are  steep,  sharp-cut,  slight]}^  scooped  out, 
and  of  a  dull  red  color  ;  and  their  base  is  depressed  and  covered 
with  a  yellow  wet-wash-leather-like  slough  and  the  debris  of 
breaking-down  tissue.  They  leave  slightly  depressed,  white  cica- 
trices, often  surrounded  with  pigmentation.  Treatment. — Con- 
stitutionally, iodide  of  potassium  should  be  given  in  full  doses, 
combined  in  obstinate  cases  with  small  doses  of  mercury  ;  whilst 
locally  a  poultice  may  be  applied  till  the  slough  has  separated, 
and  then  black  wash,  iodoform,  or  the  red  oxide  of  mercury 
ointment. 

Goaty  ukers  are  such  as  are  met  with  over  gouty  parts.  They 
are  small  and  superficial,  and  the  discharge  as  it  dries  leaves  a 
chalk-like  deposit  of  urate  of  soda  on  the  surface  of  the  ulcer. 
The  treatment  is  that  for  gout. 

The  scorbutic  idcer. — Should  an  ulcer  exist  in  a  person  affected 
with  scurvy,  its  surface  becomes  covered  by  a  spongy,  dark- 
colored,  strongly-adherent  foetid  crust,  the  removal  of  which  is 
attended  with  free  bleeding,  and  is  followed  by  the  rapid  repro- 
duction of  the  same  material.     The  treatment  is  that  for  scurvy. 

Lupous,  epithelioma  toils,  rodent,  carcinomatous,  and  sarcoma- 
tous ulcers  will  be  found  described  in  the  sections  on  Lupus, 
Tumors,  etc. 

GANGRENE    OR    MORTIFICATION. 

Although  gangrene  may  occur  from  causes  other  than  inflam- 
mation, it  is,  as  we  have  seen,  one  of  its  results,  and  is  therefore 
described  here.  It  differs  from  ulceration  in  that  the  affected 
tissue  dies  en  masse  instead  of  in  a  molecular  manner. 

Ge?ieral  outline  of  the  process. — Let  us  take  as  our  type  gan- 
grene as  it  occurs  in  a  superficial  part  as  the  result  of  inflamma- 
tion. The  part  which  was  previously  hot,  red,  painful,  and  swelled, 
becomes  cold,  gradually  falling  to  the  temperature  of  the  sur- 
rounding medium.  The  pain,  which  just  before  the  gangrene  sets 
in  is  often  of  a  peculiar  burning  character,  ceases,  and  sensation 
is  completely  lost  both  to  the  touch  and  to  other  external  stimuli. 
The  skin,  formerly  red,  becomes  of  a  peculiar  pale  earthy  color, 
mottled  in  places  with  patches  of  green  or  red.  Now  the  cuticle 
separates  in  the  form  of  blebs,  or  can  be  removed  by  gentle  rub- 
bing, leaving  the  dermis  below  wet  and  sUppery.  A  peculiar 
crepitant  sensation  is  felt  on  pressure,  on  account  of  the  forma- 
tion of  putrescent  gases  in  the  tissues,  which,  if  cut  into,  are 
found  stained  and  infiltrated  with  a  reddish  fluid.  The  part  next 
becomes  blackish-brown,  and  exhales  the  pecuhar  odor  of  decom- 
posing animal  matter.     Supposing  the  process  ceases  to  spread, 


5  2  GENERAL  PATHOLOGV   OF   SURGICAL   DISEASES. 

ulceration  is  set  up  at  the  expense  of  the  hving  tissue  bordering 
upon  the  gangrenous  part ;  a  bright  red  hne  (the  line  of  demarca- 
tion as  it  is  called)  is  thus  foraied  between  the  living  and  the 
dead ;  this  deepens,  and  finally  the  gangrenous  part  is  thrown  off 
in  the  form  of  a  sphacelus  or  slough,  leaving  a  healthy  granulating 
wound  which  cicatrizes  in  the  usual  way.  The  minute  changes 
which  occur  during  the  above  process  are  as  follows  : — In  conse- 
quence of  the  intense  action  of  the  micro-organisms  and  their 
products  on  the  v/eakened  tissues,  the  infiltration  of  leucocytes  and 
proliferation  of  connective-tissue-cells  are  so  excessive  that  the 
blood  supply  of  the  tissues  at  the  focus  of  inflammation  is  cut  off 
by  the  compression  and  thrombosis  of  the  smaller  arteries  and 
capillaries,  and  partly  owing  to  the  loss  of  the  blood  supply  and 
partly  as  the  result  of  the  direct  action  of  the  products  of  the 
micro-organisms  the  part  loses  its  vitality  and  dies.  The  red 
corpuscles  break  down,  and  their  haemoglobin  is  dissolved  in  the 
albuminous  fluid  infiltrating  the  tissues,  and  stains  them  a  deep 
red  ;  bacteria  make  their  way  through  the  skin  and  putrefaction 
sets  in.  The  tissues  disintegrate  and  liquefy,  sulphuretted  hydro- 
gen and  other  putrescent  gases  are  generated,  and  the  part 
rapidly  passes  through  changes  similar  to  those  it  wcruld  undergo 
if  it  were  no  longer  in  connection  with  the  body.  Unless  bacteria 
enter,  the  tissues  undergo  fatty  changes  {necrobiosis),  not  putre- 
faction. If  the  gangrene  ceases  to  spread,  the  living  tissues  im- 
mediately in  contact  with  the  dead  part,  owing  to  the  irritation  of 
the  micro-organisms  and  their  products,  become  intensely  in- 
flamed (hence  the  red  line  of  demarcation)  and,  subsequently, 
in  consequence  of  the  action  of  the  products  of  the  micro- 
organisms and  of  the  leucocytes  and  proliferated  tissue-cells,  with 
which  they  become  infiltrated,  soften  and  disintegrate,  and  pus  is 
formed  in  the  way  described  under  Ulceration.  The  cohesion  of 
the  tissues  being  thus  lost,  the  dead  part  is  cast  off.  Haemor- 
rhage, during  the  process  of  separation,  is  prevented  by  the 
thrombi  filling  the  vessels,  which,  subsequently,  become  perma- 
nently sealed  as  explained  in  the  section  on  Haemorrhage.  Gran- 
ulations in  the  meanwhile  spring  up  on  the  surface  of  the  ulcer 
left  on  the  removal  of  the  slough,  and  cicatrization  is  finally 
effected.  In  the  meanwhile,  if  the  gangrene  is  at  all  extensive,  or 
affects  a  vital  organ,  as  a  knuckle  of  intestine,  it  exercises  a 
marked  effect  on  the  constitution.  The  vital  powers  are  de- 
pressed, the  heart's  action  is  feeble,  the  pulse  small,  soft,  and 
quickened,  the  tongue  dry  and  brown,  the  lips  are  covered  with 
sordes,  and  the  appetite  is  lost ;  whilst  later,  as  the  products  of 
putrefaction  are  absorbed  into  the  system,  symptoms  of  septic 
poisoning  {saprcemia)  set  in. 


GANGRENE.  53 

The  above  may  be  taken  as  a  type  of  what  is  called  inflamma- 
tory gangrene.  Gangrene,  however,  may  result  from  causes  other 
than  inflammation,  and  the  dead  part,  instead  of  becoming  swol- 
len and  infiltrated  with  fluids,  may  shrivel  up  and  become  quite 
dry  and  mummified.  Hence  the  division  sometimes  made  into 
moist  and  dry  gangrene. 

The  moist  or  dry  appearance  of  the  part  depends  to  a  great 
extent  upon  whether  the  tissues  at  the  time  that  gangrene  super- 
venes are  charged  with  blood,  as  \\\  inflammatory  gangrene  and 
in  gangrejie  from  venous  obstruction  ;  or,  whether  they  are  more 
or  less  deprived  of  blood,  as  in  gangrene  from  the  blocking  of  the 
main  artery  supplying  the  part.  The  two  conditions  sometimes 
run  into  one  another,  the  dead  part  at  first  being  moist,  and  sub- 
sequently becoming,  as  the  fluids  evaporate,  more  or  less  dry. 
The  different  appearances  presented  by  the  gangrenous  part  will 
be  further  described  under  Varieties  of  Gangrene,  as  it  varies  ac- 
cording to  the  cause  producing  it.  The  causes  of  gangrene, 
therefore,  must  first  be  considered. 

Causes. — The  immediate  cause  of  gangrene,  whether  the  pro- 
cess is  induced  by  inflammation,  as  described  above,  or  otherwise, 
may  be  said*to  be  any  agent  which  is  capable  of  destroying  the 
vitahty  of  the  tissues  or  cutting  off  their  nutrient  supply.  The 
agents  capable  of  inducing  one  or  other  or  both  of  these  condi- 
tions are  very  numerous.  Some  of  them  are  in  themselves  alone 
sufficient  to  act  in  this  way.  For  others,  however,  to  become 
operative,  certain  prior  changes  in  the  tissues  would  appear  to  be 
necessary.  The  causes  of  gangrene,  therefore,  may  be  considered 
under  the  heads  of  predisposing  and  exciting. 

The  Predisposing  causes  are  such  as  impair  the  vitality  of  the 
tissues,  and  render  them  less  able  to  resist  injurious  influences. 
They,  therefore,  include  those  already  given  under  Inflammation 
(p.  2i),  and  amongst  them  may  be  especially  mentioned  old  age, 
feeble  action  of  the  heart,  chronic  congestion  of  a  part,  deteri- 
orated blood  as  in  diabetes  and  Bright's  disease,  and  impairment 
or  loss  of  nerve  influence  from  injury  or  disease  of  the  nerve-cen- 
tres or  nerve-trunks. 

Exciting  causes. — These  may  be  considered  under  the  following 
heads: — i.  Physical  or  chemical  agencies,  which  act  by  directly 
destroying  the  vitality  of  the  tissues.  Among  these  may  be 
mentioned  mechanical  violence,  as  a  severe  crushing  of  the  whole 
or  a  part  of  a  limb ;  excessive  heat,  as  in  burns  and  scalds  ;  in- 
tense cold,  as  in  frost-bite ;  chemical  action  from  strong  acids, 
alkalies,  putrid  secretions,  and  the  like.  Although  these  may  act 
by  directly  killing  the  tissues  of  the  part,  their  action  is  often 
aided  by  inflammation,  as  seen  for  instance  in  a  crushed  foot, 


54  GENERAL   PATHOLOGY    OF   SURGICAL   DISEASES. 

where  both  the  injury  and  the  subsequent  inflammation  determine 
the  death  of  the  member.  2.  Inflammatio7i  causes  gangrene  in 
part  by  the  pressure  of  the  inflammatory  exudation  and  the 
thrombosis  of  the  vessels  cutting  off  the  nutritive  supply,  but 
chiefly  by  the  action  of  the  irritant  causing  the  inflammation. 
The  latter  is  especially  the  case  in  the  septic  and  infective  inflam- 
mations, the  noxa  here  being  either  the  products  of  putrefaction 
or  micro-organisms,  especially  the  streptococcus  pyogenes.  Some 
inflammations  always  terminate  in  gangrene,  as  carbuncle.  The 
manner  in  which  micro-organisms  produce  gangrene  is  not  deter- 
mined, but  it  is  believed  to  be  due  to  the  action  of  their  products 
on  the  tissues.  3.  Obsfi-iiction  to  the  arterial  supplx,  as  from  liga- 
ture of  the  main  artery,  embolism,  thrombosis  or  rupture  of  the 
arter}'  supplying  the  part,  and  spasm  of  the  arterioles  due  to  long 
ingestion  of  ergot.  4.  Obsfj-uction  to  the  capillary  circulation 
from  thrombosis  or  pressure.  As  examples  of  this  may  be  men- 
tioned, bed-sores  from  pressure  of  the  part  between  the  bed  and 
a  point  of  bone  ;  the  death  of  the  skin  and  bone  in  cellulitis  and 
periostitis  respectively  from  compression  of  the  capillaries  by  the 
inflammatory  effusion  ;  local  sloughing  from  the  pressure  of  a 
splint  or  a  new  growth  ;  cancrum  oris  from  thrombosis  of  the  capil- 
laries, &c.  5.  Obstruction  to  the  venous  return  as  seen  in  strang- 
ulated hernia,  paraphimosis,  tight  bandaging,  &c.  Obstructed 
venous  return,  however,  is  generally  associated  with  obstruction 
to  the  arterial  supply  as  well. 

The  signs  of  gangrene  vary  considerably  according  to  the  cause. 
The  general  symptoms  in  the  acute  inflammatory  form  have 
already  been  given  in  the  outline  of  the  process  (p.  51).  Those 
of  the  special  forms  will  be  further  mentioned  under  varieties  of 
gangrene  and  elsewhere,  as  in  section  on  Cancrum  oris,  &c. 

The  Treatment,  like  the  symptoms  of  gangrene,  depends  so 
much  upon  the  cause  and  nature  of  the  gangrene,  that  its  details 
can  only  be  given  under  the  special  varieties.  Here,  however,  it 
may  be  said,  that  the  general  indications  for  treatment,  whatever  the 
variety,  are — (i)  To  remove  where  possible  the  cause,  as  a  tight 
bandage  constricting  a  limb,  putrefactive  processes  in  wounds, 
tension,  pressure,  and  so  on.  (2)  To  prevent  gangrene,  when 
threatened,  from  actually  occurring  by  maintaining  the  warmth  of 
the  part,  and  endeavoring  to  reheve  the  embarrassed  circulation 
by  elevating  the  limb,  and  by  gentle  friction  when  there  is  venous 
congestion;  and  (3)  When  gangrene  has  actually  occurred,  to 
check  it  spreading ;  to  promote  the  separation  of  the  dead  from 
the  living  ]jart,  or  remove  it  by  amputation ;  to  control  as  far  as 
possible  the  formation  of  the  products  of  putrefaction  by  keeping 
the  part  dry,  and  by  the  free  use  of  antiseptics ;  to  support  the 


GANGRENE.  55 

patient's  strength,  to  counteract  the  deleterious  effects  on  the  con- 
stitution from  the  absorption  of  septic  poison ;  and  to  soothe  pain 
by  opium. 

Varieties  of  gangrene. — We  have  just  seen  that  gangrene  is  gen- 
erally divided  into  the  moist  and  dry  according  to  the  condition 
of  the  gangrenous  part.  Although  these  may  be  looked  upon  as 
more  or  less  accidental  conditions,  depending  upon  the  amount 
of  fluid  in  the  tissues  at  the  time  that  gangrene  supervenes,  they 
are  convenient  for  the  purpose  of  classification,  and  are  thus  used 
here.  As  examples  of  moist  gangrene  may  be  mentioned — (i) 
Inflammatory  gangrene,  (2)  Traumatic  gangrene,  (3)  Hospital 
gangrene,  (4)  Phagedaena,  (5)  Cancnnn  oris  and  Noma,  (6) 
Carbuncle,  (7)  Bed-sores,  (8)  Diabetic  gangrene.  As  examples 
of  the  dry — (i)  Senile  gangrene,  (2)  Gangrene  from  embolism 
or  Hgature  of  a  main  artery,  (3)  Gangrene  from  frost-bite,  and 
(4)  Raynaud's  disease.  Thus  it  will  be  seen  that  there  may  be 
made  almost  as  many  varieties  of  gangrene  as  there  are  causes 
producing  it.  Here  only  a  brief  account  of  a  few  of  the  typical 
varieties  can  be  given ;  others,  as  Hospital  gangrene,  Phagedaena, 
Cancrum  oris,  &c.,  are  described  in  the  sections  on  septic  pro- 
cesses in  wounds,  Diseases  of  the  Cheeks,  Skin,  &c. 

Traumatic  gangrene  may  be  divided  into  the  local  and  the 
spreading. 

Local  traumatic  gangrene  is  of  common  occurrence  in  surgical 
hospital  practice.  It  may  be  the  result  of  a  severe  injury,  such  as 
the  crushing  of  a  limb,  whereby  the  tissues  are  killed  outright  or 
their  vitality  is  so  lowered  that  the  blood  extravasated  from  the 
wounded  vessels  is  sufficient  in  addition  to  the  lowering  of  their 
vitality  to  kill  them.  Again,  it  may  be  due  to  the  rupture  of  a 
main  artery  or  vein  without  any  lesion  of  the  skin.  The  symptoms 
in  these  cases  are  as  follows  : — The  limb  is  cold  and  swollen,  its 
sensibility  is  lost  or  blunted,  and  the  pulse  below  the  seat  of  in- 
jury is  indistinguishable.  As  the  patient  recovers  from  the  shock 
of  the  injury  the  circulation  may  return,  and  all  may  be  well ;  or 
the  vitality  of  the  part  may  become  completely  lost,  the  skin  dis- 
colored, and  the  other  signs  of  putrefaction,  already  described, 
set  in.  Here  the  process  is  entirely  a  local  one,  and  is  dependent 
neither  on  constitutional  disturbance,  inflammation,  nor  septic 
agencies.  But  if  the  limb  be  not  removed,  the  septic  products 
will  give  rise  to  local  inflammation  and  to  constitutional  signs  of 
blood-poisoning.  The  treatment  consists  in  amputation  well 
above  the  gangrenous  part  as  soon  as  the  diagnosis  is  thoroughly 
established ;  but  as  long  as  it  is  doubtful  whether  the  limb  will 
not  recover,  the  part  should  be  handled  with  all  gentleness,  kept 
warm  with  cotton-wool,  and  placed  at  rest  on  a  pillow,  while 


56  GENERAL   PATHOLOGY    OF   SURGICAL   DISEASES. 

Stimulants  should  be  administered,  and  tight  bandaging  and 
splints  avoided,  as  such  might  be  sufficient  to  determine  the  death 
of  the  part. 

Spreaditig  traumatic  gangrene  is  a  much  more  serious  affection. 
Here  the  gangrene  spreads  with  fearful  rapidity  towards  the  trunk, 
and  is  attended  with  severe  constitutional  symptoms.  It  occurs 
in  two  forms,  one  of  which  appears  to  depend  upon  the  consti- 
tutional condition  of  the  patient,  and  is  unattended  with  inflamma- 
tion ;  the  other  upon  an  infective  inflammation.  The  former 
occurs  in  persons  whose  vitality  has  been  lowered  by  previous 
ill-health  or  internal  injury.  It  usually  comes  on  about  the 
second  or  third  day,  after  an  injury  that  has  been  generally  though 
not  necessarily  severe.  The  limb  becomes  swollen,  cold,  and  of 
an  earthy  or  leaden  hue,  and  the  gangrene  rapidly  extends  towards 
the  trunk  unattended  with  any  local  sign  of  inflammation ;  the 
patient  falls  into  a  typhoid  condition,  and  sinks  as  the  gangrene 
reaches  the  trunk.  The  second  or  infective  form  is  most  frequent 
after  severe  crushes  or  bruises  of  a  limb,  especially  the  lower, 
with  injury  of  the  bone,  as  compound  fracture  attended  with  ex- 
travasation and  retention  of  blood  or  serum  in  the  tissues.  The 
gangrene  begins  at  the  edge  of  the  wound  and  spreads  up  towards 
the  trunk,  but  is  preceded  by  a  blush  of  inflammatory  redness 
and  emphysem.a  of  the  tissues.  In  this  case  the  gangrene  is 
probably  the  result  of  an  infective  micro-organism  in  the  wound 
{bacillus  ocdeniatis  maligni)  ;  the  system  becomes  poisoned  by  the 
absorption  of  the  products  of  bacterial  growth  ;  and  the  ordinary 
signs  of  septic  intoxication  {saprcruiia)  ensue. 

Treatment. — In  the  first  variety,  depending  on  the  constitu- 
tional condition  of  the  patient,  no  treatment  hitherto  has  been  of 
any  avail,  as  the  gangrene  almost  invariably  occurs  in  the  flaps  if 
amputation  is  performed.  In  the  second  variety,  amputation,  as 
far  removed  from  the  injury  and  gangrene  as  possible,  should  be 
resorted  to  early,  so  as  to  be  well  above  the  infiltrated  tissues.  It 
is  of  no  use  waiting  for  a  line  of  demarcation,  as  one  does  not 
form.  The  strength  must  be  supported  by  stimulants  and  fluid 
nourishment,  and  opium  given  to  relieve  pain.  As  the  gangrene 
often  spreads  higher  along  the  inner  side  of  the  limb  than  the 
outer,  the  flaps  should  in  such  cases  be  taken  from  the  outer  side, 
so  as  the  better  to  avoid  the  infiltrated  tissues. 

Senile  (;an(;rene  is  generally  taken  as  a  typical  example  of  the 
dry  variety,  but  is  often  more  or  less  moist  when  starting  in 
inflammatory  action.  It  is  usually  the  result  of  calcification  or  of 
atheroma  of  the  arteries  and  consequent  clotting  of  blood  on  their 
roughened  surface,  a  cause  rendered  more  effective  in  old  people 
by  the  weak  propelling  action  of  the  heart,  and  feeble  circulation 


GANGRENE.  57 

through  the  lower  limbs.  It  rtay  occasionally  be  produced  by 
embolism.  It  often  begins  apparently  spontaneously  as  a  black 
spot  on  one  of  the  toes  or  the  side  of  the  foot ;  or  it  may  start  as  a 
slight  or  diffuse  inflammation  induced  by  cutting  a  corn,  a  trivial 
injury  of  the  foot,  or  ulceration  of  a  bunion,  and  is  often  preceded 
by  coldness  and  numbness,  or  cramp  in  the  feet.  It  may  gradu- 
ally involve  the  whole  foot  and  part  of  the  leg,  the  parts  becom- 
ing dry,  black,  and  shrivelled.  The  process  of  separation  is 
usually  very  slow,  and  at  first  is  attended  with  very  little  constitu- 
tional disturbance.  It  frequently  terminates  fatally.  Treatment. 
— It  is  generally  held  that  the  parts  should  be  allowed  to  separate 
spontaneously,  the  surgeon  merely  stepping  in  to  help  nature  by 
severing  the  bone  or  any  tendons  that  may  remain  after  the  softer 
tissues  have  separated.  If  this  treatment  is  followed  the  limb  in 
the  meantime  should  be  kept  at  a  uniform  temperature  by  wrap- 
ping it  in  cotton-wool ;  the  odor  of  the  gangrenous  part  kept  in 
check  by  dressings  of  iodoform  or  dried  charcoal ;  the  strength 
supported  by  fluid  nourishment  and  stimulants  ;  and  pain  relieved 
and  the  circulation  controlled  by  small  doses  of  opium.  The  re- 
sult of  this  treatment,  however,  is  at  the  best  unsatisfactory.  It 
has  been  proposed  by  Mr.  Hutchinson,  therefore,  to  amputate  at 
a  distance  from  the  gangrene,  e.g.,  through  the  thigh  in  gangrene 
of  the  foot,  the  objection  to  amputation  in  the  neighborhood 
being  the  liability  of  the  flaps  to  slough,  the  risk  of  secondary 
haemorrhage,  and  the  difficulty  of  securing  the  arteries.  These 
dangers  have  probably,  however,  been  much  lessened  since  the 
introduction  of  antiseptics,  and  successful -cases  of  amputation 
through  the  thinnest  part  of  the  leg — a  much  less  severe  pro- 
cedure in  itself  than  amputation  through  the  thigh — have  been 
reported. 

Diabetic  gangrene,  as  the  name  implies,  occurs  in  persons  the 
subjects  of  diabetes.  The  exciting  causes  of  the  gangrene  are 
probably  the  same  as  in  other  forms,  though  arterial  disease  and 
peripheral  neuritis  would  appear  to  be  the  most  common.  Diabetic 
gangrene  in  some  respects  resembles  senile  gangrene  in  that  it 
usually  occurs  in  moderately  old  people,  starts  in  the  lower  ex- 
tremity, frequently  in  the  toes  or  the  sole  of  the  foot,  and  is  gen- 
erally the  result  of  a  trifling  injury,  or  an  inflamed  corn,  or,  at 
times,  of  a  perforating  ulcer.  It  usually  spreads  more  rapidly, 
however,  shows  little  tendency  to  be  limited  by  a  line  of  demarca- 
tion, and  instead  of  being  dry,  generally  remains  moist.  The 
activity  of  the  gangrene  would  appear  to  depend  upon  the  weak- 
ened tissues  in  diabetes  being  unable  to  resist  the  action  of  micro- 
organisms and  their  products,  and  forming  a  favorable  nidus  for 
their  growth.     Mr.  Gcdlee  would  distinguish  two  chief  forms  of 


58  GENERAL   PATHOLOGY   OF   SURGICAL   DISEASES. 

diabetic  gangrene  : — In  one,  depending  upon  arterial  disease,  the 
spread  is  rapid,  the  pain  great,  and  there  is  little  tendency  to  the 
formation  of  a  line  of  demarcation.  In  the  other,  depending 
upon  peripheral  neuritis,  the  progress  is  slow,  the  pain  slight,  and 
spontaneous  separation  may  occur.  Treatment. — Hitherto  ampu- 
tation has  been  generally  deemed  inadmissible  for  fear  of  slough- 
ing of  the  flaps,  and  the  treatment  has  consisted  of  dry  antiseptic 
dressings,  dieting  and  opium.  Recently,  however,  amputation  at 
a  distance,  /.  e.,  through  the  thigh  in  gangrene  of  the  foot,  has 
been  successful  in  the  hands  of  Godlee,  Spencer,  and  others.  In 
the  rapidly  spreading  form  amputation  at  a  distance  is  perhaps 
the  best  treatment,  since  the  arterial  disease  generally  extends  to 
the  knee,  but  not  further.  In  the  more  slowly  spreading  forms 
the  part  may  be  left  to  separate  spontaneously,  or  be  removed 
just  above  the  gangrenous  spot.  In  all  cases  the  strictest  anti- 
septic precautions  must  be  taken.  Do  what  we  will,  however, 
there  is  always  a  danger  of  death  from  diabetic  coma,  a  condition 
which  is  liable  to  follow  the  most  trivial  operation  in  diabetics. 

Raynaud's  Disease  is  a  peculiar  form  of  spontaneous  gangrene 
usually  affecting  symmetrically  the  fingers,  toes,  and  more  rarely 
the  ears.  It  as  a  rule  occurs  in  children  or  young  persons  who 
have  previously  suffered  for  a  longer  or  shorter  period  from  inter- 
mittent attacks  of  numbness  and  coldness  of  the  extremities, 
generally  brought  on  by  cold  weather  {local  syncope),  followed 
later  in  many  cases  by  blueness  and  coifigestion,  accompanied  by 
burning  pain  {local  asphyxia),  which,  in  its  turn,  shows  a  tendency 
to  run  into  actual  death  of  the  part  {gangrene).  The  gangrene 
is  usually  of  the  dry  kind,  but  in  the  toes  and  shins  a  bleb  often 
forms,  and  the  parts  slough  {moist  gangrene).  This  condition  is 
supposed  to  depend  upon  some  disturbance  of  the  vaso- motor 
nerve-centre  inducing  spasm  of  the  arterioles,  or  in  some  cases 
upon  a  peripheral  neuritis,  but  no  organic  lesion  has  yet  been 
discovered.  Hsematinuria  is  frequently  observed  in  association 
with  it.  It  does  not  appear  at  present  to  have  ended  fatally. 
Treatment. — The  constant  descending  current,  as  recommended 
by  Raynaud,  or  placing  the  parts  in  an  electric  bath,  has  been 
attended  with  good  results  before  gangrene  has  set  in.  When 
this  has  occurred  it  must  be  treated  on  general  principles  till  the 
parts  have  separated.  Opium  and  trinitrine  tabloids  internally, 
and  massage  and  belladonna  locally,  have  been  recommended 
when  the  gangrene  attacks  the  ears. 

TUBERCLE  AND  TUBERCULOSIS. 

TuBERCi-E  is  a  new  growth  depending  upon  the  presence  of  the 
tubercle  bacillus,  and  capable  of  inducing  tuberculosis  by  trans- 


TUBERCLE   AND   TUBERCULOSIS. 


59 


Fig.  7. 


ference  to  most  animals.  Tubercle  may  be  limited  to  one  set  of 
tissues,  or  to  an  organ  {local  tuberculosis) .  Or  it  may  be  gen- 
erally diffused  throughout  the  whole  body  {getio-al  tuberculosis). 

Structure  of  tubercle.— Tubercle  is  met  with  under  two  forms, 
grey  miliary  nodules  and  yellow  caseous  masses,  (a)  The  grey 
miliary  tubercles  have  almost  the  lustre  and  hardness  of  cartilage. 
They  are  globular  in  shape  and  vary  in  size  from  a  pin's  point  to 
a  millet  or  mustard  seed.  They  are  sharply  defined,  and  may  be 
scattered  throughout  an  organ  or  on  a  serous  surface,  or  be 
grouped  more  or  less  closely,  {b)  The  yellow  caseous  masses 
are  soft  in  consistency  and  larger  than  the  miliary  tubercles,  the 
larger  masses  being  produced  by  the  fusion  of  several  tubercles. 
Yellow  tubercle  is  believed  to  be  due  to  the  degeneration  of 
miliary  tubercle.  In  some 
cases  of  general  tuberculosis 
only  the  miliary  form  may 
be  found,  in  other  cases  only 
the  yellow  variety ;  but  fre- 
quently the  two  forms  are 
mixed,  and  the  various 
stages  from  grey  to  yellow, 
from  the  central  softening 
of  the  miliary  tubercle  to 
its  complete  conversion  into 
a  caseous  yellow  mass,  can 
be  traced. 

Microscopically  a  typical 
grey  granulation  when  of 
some  size  is  seen  to  consist 
of  some  smaller  nodules 
aggregated  together,  whilst 
each  of  these  again  is  composed  of  cells  of  various  shapes  and 
sizes,  arranged  in  three  zones  (see  Fig.  7).  The  inner  zone 
is  formed  by  one  or  more  large  branching  so-called  giant-cells, 
composed  of  a  granular  protoplasm,  in  which  many  large  distinct 
oval  nuclei  containing  nucleoli  are  found.  The  next  zone  consists 
of  large  single-nucleated  cells,  arranged  between  the  branches  or 
processes  of  the  giant-cells,  which  ramify  through  the  zone.  These 
cells  are  called  epitheloid,  from  their  resemblance  to  epithelial 
cells.  The  third  or  outermost  zone  consists  of  lymphoid  cells, 
like  ordinary  leucocytes,  scattered  through  a  delicate  reticulum  of 
branched  connective-tissue  cells,  which  is  sometimes  continuous 
with  the  processes  of  the  giant-cells.  There  is  no  distinct  line 
of  demarcation  between  the  outer  zone  of  lymphoid  cells  and 
the  surrounding  tissues.     The  tubercle-nodule,  though  sometimes 


Diagram  of  the  minute  structure  of  tubercle. 


6o  GENEIL4L   PATHOLOGY   OF   SURGICAL   DISEASES. 

seated  upon  a  small  vessel,  is  itself  completely  non-vascular.    The 
bacilli   may  be  found  in  the  giant-cells,  especially  in  animals,  and 
in  and  amongst  the  epithelial  cells.     They  are  less  readily  discov- 
ered after  caseation  has  commenced. 
Fig.  8.  They   are    rod-like   bodies,   usually 

straight,  sometimes  curved,  rounded 
at  the  ends,  and  about  one-fifth 
their  length  in  breadth  (see  Fig.  8). 
Although  the  above  may  be  re- 
garded as  the  typical  microscopical 
appearance  of  a  miliary  tubercle, 
often  neither  giant-cells  nor  epith- 
elioid cells  are  present,  while  both 
these  may  be  found  in  chronic  in- 
flammations which  are  not  tubercular. 
Development  of  tubercle. — The 
The  tub^^baciiius.  tubercle  bacilli    having   gained  en- 

(After  Macintyre.)  trauce  to  the  bodv  may  remain  at 

the  point  of  entrance  or  be  carried 
by  the  blood  or  lymph  stream  to  other  and  perhaps  distant  parts. 
A  tubercular  nodule  commences  by  the  proliferation  of  the  tis- 
sue cells  at  the  spot  where  the  bacilli  may  have  lodged.  Nuclear 
and  cell  division  give  rise  to  an  aggregation  of  young  epithehoid 
cells.  At  this  stage  small  round  cells  (leucocytes)  make  their 
appearance  at  the  circumference  of  the  zone  of  epithelioid  cells. 
The  giant  cells  are  probably  formed  by  the  growth  of  a  single  or 
fusion  of  several  epitheloid  cells  accompanied  by  division  of  the 
nucleus  or  nuclei.  They  are  therefore  of  later  development,  and 
to  some  extent  are  a  sign  of  chronicity.  Giant  cells  are  not  an 
essential  part  of  a  tubercular  nodule,  and  may  be  present  in  any 
chronic  inflammation. 

Secofidary  changes. — (i)  Tubercle,  probably  on  account  of  the 
absence  of  blood-vessels  and  the  ])ressure  of  the  invading  leuco- 
cytes, and  possibly  also  on  account  of  the  noxious  influence  of 
the  bacilli,  is  very  liable  to  undergo  caseous  degeneration.  This 
change  begins  at  the  centre  of  the  tubercle;  in  the  giant-cells,  and 
spreads  outwards.  (2)  In  chronic  tuberculosis,  instead  of  casea- 
tion occurring,  a  capsule  of  fibrous  tissue  may  Ise  formed  around 
the  nodule,  and  the  cicatrization  extending  inwards  until  the 
giant-cell  is  involved,  the  whole  tubercle  may  be  converted  into  a 
mass  of  fibrous  tissue.  The  tubercle  baciflus  is  not  foimd  under 
such  conditions.  (3)  After  caseation  has  occurred  the  tubercle 
may  become  encysted,  or  may  tmdergo  calcification,  in  both  of 
which  states  it  may  remain  harmless;  or  (4)  it  may  become  in 
fected  with  pyogenic  micrococci,  which,  acting  as  irritants,  set 


TUBERCLE  AND  TUBERCULOSIS.  6l 

up  inflammation  and  suppuration  in  the  tissues  around,  leading  to 
the  formation  of  an  abscess,  and  subsequently  on  its  bursting  to 
an  ulcer. 

Cause. — The  immediate  exciting  cause  of  tubercle  would  ap- 
pear to  be  the  presence  of  the  tubercle  bacillus.  The  bacillus  is 
believed  in  man  to  gain  admission  (i)  by  the  digestive  tract,  as 
in  the  saliva  of  a  phthisical  mother  or  nurse,  in  milk  taken  from 
cows  with  tuberculous  uddeis,  or  in  imperfectly-cooked  tubercu- 
lous meat;  (2)  by  the  respiratory  tract,  as  by  close 'and  long 
contact  with  the  breath  of  phthisical  patients,  inhalation  of  the 
dust  of  dried  phthisical  sputa,  etc.,  and  (3)  by  the  skin.  It  is 
still  doubtful  if  man  is  often  inoculuted  through  the  skin  ;  at  any 
rate  there  then  seems  little  or  no  tendency  for  tubercle  to  spread 
beyond  the  point  of  inoculation. 

Predisposing  causes. — For  the  bacillus  to  take  effect  a  lowering 
of  the  vitahty  or  resisting  power  of  the  tissues  appears  to  be  nec- 
essary. Such  a  condition  of  the  tissues  may  be  present : — (1)  In 
children  born  of  phthisical  parents.  Hence  heredity  in  this  sense 
may  be  said  to  be  one  of  the  chief  predisposing  causes,  but  it 
must  be  remembered  that  tubercle  is  not  transmitted  from  the 
parent  to  the  offspring,  as  is  syphilis  ;  (2)  In  the  so-called  strumous 
diathesis,  and  (3)  In  certain  states  of  the  system  induced  by  bad 
hygiene  and  food,  and  imperfect  assimilation  of  food  and  conse- 
quent impairment  of  nutrition.  Tubercle  is  most  common  in  the 
young,  but  adults,  and  even  old  people,  are  liable  to  it  when  ex- 
posed to  like  unfavorable  conditions,  a  slight  inflammation  or 
injury  then  generally  forming  the  starting  point. 

Dissemination  of  tubercle. — The  bacillus  having  gained  admis- 
Fion  in  one  or  other  of  the  above-mentioned  ways  is  believed  to 
set  up  the  tubercular  process  as  previously  described.  The  tu- 
bercular process  may  then  (i)  remain  confined  to  the  seat  of 
inoculation,  as  in  some  forms  of  tubercle  of  the  skin.  Or  (2) 
with  or  without  any  local  manifestation  it  may  spread  by  the 
lymphatics  to  the  nearest  lymphatic  glands,  and  there  become 
arrested.  As  an  example  of  this  may  be  mentioned  the  tubercu- 
lous or  so-called  strumous  enlargement  of  the  glands  of  the  neck, 
in  which  the  bacillus  is  believed  to  gain  admission  through  a 
crack  or  small  ulcer  of  the  mucous  membrane  of  the  mouth  or 
through  an  inflamed  tonsil.  Again  (3)  the  bacillus  may  pass  the 
glands  and  enter  the  circulation,  and  then  either  {a)  become 
lodged  in  some  organ  or  distant  part  of  the  body,  as  the  testicle, 
a  bone  or  a  joint,  or  {b)  become  disseminated,  setting  up  general 
acute  tuberculosis.  The  brunt  of  the  affection  falls  in  the  latter 
case  either  on  the  lungs,  acute  tubercular  phthisis,  or  on  the 
membranes   of  the   brain,  acute    tubercular   meningitis.     When 


62  GENERAL   PATHOLOGY   OF   SURGICAL   DISEASES. 

affecting  an  organ  or  tissue,  as  a  testicle  or  a  joint,  it  may  remain 
localized  for  a  longer  or  shorter  time,  and  even  become  cured  ; 
or  it  may  set  up  inflammation,  and  involve  and  destroy  the  whole 
organ ;  or  finally  become  generally  disseminated  through  the 
system,  leading  to  general  tuberculosis. 

Localizatioji  of  Tubercle. — Tubercle  has  a  special  affinity  for 
certain  organs  and  tissues  to  the  exclusion  of  others.  Serous 
membranes,  such  as  the  pleura,  peritoneum,  pia  mater,  and 
arachnoid,  are  especially  liable  to  be  affected  ;  vi^hilst,  on  the  other 
hand,  the  pericardium  and  the  tunica  vaginalis  show  an  immunity. 
Of  all  organs  the  lung  is  most  prone  to  suffer  ;  next,  though  much 
less  frequently,  the  testicle,  kidney,  brain,  liver,  spleen,  supra- 
renals  and  ovaries.  The  larynx  and  intestines  may  become 
involved  by  the  bacillus  coming  into  contact  with  them  either  in 
the  breath  or  swallowed  sputa ;  yet  the  trachea,  the  stomach  and 
the  upper  part  of  the  intestine  generally  escape.  The  bones  and 
joints  are  frequent  seats  of  the  disease,  which  has  a  special  pre- 
dilection for  the  cancellous  ends  of  the  long  bones  and  the  short 
bones.  The  upper  end  of  the  femur  and  hip-joint,  the  ends  of  the 
femur  and  tibia  forming  the  knee-joint,  and  the  short  bones  and 
joints  of  the  foot  and  hand  are  most  often  affected,  the  elbow-joint 
less  often,  and  the  upper  end  of  the  humerus  and  the  clavicular 
joints  but  rarely.  The  scapula  and  ilium  with  the  acetabulum 
may  suffer,  but  the  shafts  of  the  long  bones,  the  clavicle,  and  the 
ischium  and  pubes,  apart  from  the  acetabulum,  escape.  The 
bodies  of  the  vertebrse  are  frequently  attacked,  while  the  laminae, 
with  the  spinous  and  transverse  processes,  remain  free.  The  bones 
of  the  skull  are  rarely  involved,  those  of  the  jaws  and  face  never. 
Tuberculosis  may  occur  in  the  skin  and  affect  the  glands,  but 
lupus,  which  is  believed  to  be  a  form  of  tuberculous  disease,  does 
not  spread  to  the  glands.  The  reason  for  tubercle  affecting  any 
special  organ  or  tissue  is  not  known,  but  it  is  thought  to  depend 
on  some  previous  lowering  of  vitality  of  the  part,  as  a  sprain  of  a 
joint,  a  blow  on  the  testicle,  etc. 

A  general  though  brief  account  of  tubercle  has  been  here  given 
to  prevent  repetition  when  treating  of  tubercular  diseases  of  cer- 
tain organs.  As  a  surgical  affection,  it  is  chiefly  met  with  in  the 
bones,  joints,  testicle,  lymphatic  glands,  skin,  larynx,  and  more 
rarely  in  the  bladder  and  rectum.  All  that  need  here  be  said  is, 
that  such  lesions  are  of  a  very  chronic  and  indolent  nature  ;  that 
they  are  set  up  by  very  slight  and  apparently  inadequate  causes ; 
that  they  exhibit  a  marked  tendency  to  suppuration  and  progres- 
sive destruction  or  undermining  of  the  tissues,  and  but  little  ten- 
dency to  repair ;  that  they  are  often  productive  of  much  scarring 
and  deforming,  as  when  they  occur  as  abscesses  in  the  neck  ;  that 


STRUMA.  63 

they  are  generally  very  obstinate  and  intractable  as  regards  treat- 
ment ;  and  that  they  may  terminate  in  general  dissemination  of 
the  tubercle  through  the  body  and  death. 

The  treatment  should  be  both  constitutional  and  local.  Thus, 
the  patient  should  be  placed  under  as  perfect  hygienic  conditions 
as  possible,  with  residence  at  the  seaside,  preferably  Cromer  or 
Margate,  or  where  possible  he  may  go  a  sea  voyage.  The  diet 
should  be  nourishing  but  unstimulating,  with  plenty  of  milk  and 
cream,  whilst  cod-liver  oil  or  maltine  and  the  syrup  of  the  iodide 
or  phosphate  of  iron  are  especially  indicated.  Koch's  tubercuHn 
has  now  had  extensive  trial  in  surgical  tubercular  affections.  My 
own  experience  of  it  has  been  unfavorable,  and  such  would  appear 
to  be  that  of  the  majority  of  Surgeons.  A  grave  objection  is  the 
danger  of  setting  up  general  tuberculosis.  The  local  treatment 
required  for  the  various  lesions  that  may  be  present  is  given  when 
describing  these  lesions  as  they  occur  in  special  tissues  and  organs. 

STRUMA  OR  SCROFULA. 

The  terms  struma  and  scrofula  are  here  used  synonymously. 
To  prevent  confusion  the  former,  as  perhaps  the  one  in  more 
general  use,  will  be  subsequently  employed.  By  struma  or  stru- 
mous is  generally  understood  a  constitutional  condition  or  diathe- 
sis, in  which,  on  very  sHght  provocation,  chronic  inflammations  of 
certain  tissues  and  organs,  preferably  skin,  mucous  membrane, 
lymphatic  glands,  bones,  joints  and  testicle  are  set  up,  run  an 
indolent  course,  and  have  a  marked  tendency  to  caseation  and 
suppuration.  By  many  pathologists,  however,  these  chronic  in- 
flammatory processes,  which  have  been  supposed  to  be  character- 
istic of  struma,  are  considered  to  be  in  themselves  of  a  tuberculous 
nature,  and  dependent  on  the  presence  of  the  tubercle  bacillus ; 
whilst  what  is  here  called  the  strumous  diathesis  is  regarded  by 
them  merely  as  a  phase  of  ill-health  or  malnutrition,  favorably 
disposing  the  subject  to  tubercular  infection.  Such  observers, 
therefore,  regard  the  terms  strumous  and  tuberculous  as  synony- 
mous. The  histological  characters  and  the  general  behavior  of 
many  of  the  so-called  strumous  inflammations  are  no  doubt  in 
many  respects  similar,  if  not  identical,  to  those  which  are  on  all 
hands  regarded  as  tuberculous,  and  in  many  of  them  the  tubercle 
bacillus  has  been  found.  In  others,  however,  even  after  a  careful 
search,  it  has  not  been  discovered ;  and  if,  therefore,  the  pres- 
ence of  the  tubercle  bacillus  is  to  be  taken  as  distinctive  evidence 
of  tubercle,  all  the  so-called  strumous  inflammations  are  not 
tuberculous.  The  constitutional  condition  or  diathesis,  more- 
over, regarded  by  surgeons  as  strumous,  is  certainly  something 
more,  though  difficult  to  define,  than  a  mere  state  of  debility  or 


64  GENERAL   PATHOLOGY    OF   SURGICAL   DISEASES. 

feeble  health.  It  would  appear,  therefore,  that  the  so-called 
strumous  inflammations,  though  often  tubercular,  are  sometimes 
of  a  simple  chronic  character,  and  only  distinguishable  from  ordi- 
nary chronic  inflammations  by  the  indolence  of  their  course  and 
the  tendency  of  their  products  to  undergo  caseation  or  become 
secondarily  infected  by  the  tubercle  bacillus.  And  further  that 
the  strumous  condition  or  diathesis  is  a  constitutional  state  in 
which  certain  tissues  and  organs  possess  a  feeble  resisting  power, 
and  are  hence  exceedingly  liable  to  be  infected  by  the  tubercle 
bacillus  or  on  very  slight  injury  to  become  inflamed,  whilst  the 
most  trifling  irritation,  as  friction,  tension,  or  pressure,  is  then 
sufficient  to  keep  such  inflarmiiation  up. 

The  causes  of  the  condition  known  as  the  strumous  diathesis 
are  hardly  known,  but  it  is  thought  to  be  hereditary,  and  has  been 
attributed  to  bad  hygienic  conditions  of  all  kinds,  as  impure  air, 
dark  and  damp  dwellings,  improper  or  insufficient  food,  &c.  It 
is  said  to  be  especially  common  in  children  born  of  dyspeptic  or 
phthisical,  or  very  young  or  very  old  parents.  Syphilis  in  the 
parent  is  also  believed  by  some  to  be  a  cause. 

Symptoms. — The  general  symptoms  which  are  usually  regarded 
as  strumous,  irrespective  of  any  of  the  local  lesions,  as  enlarge- 
ment of  the  tonsils  or  of  the  lymphatic  glands,  eczeraatous  erup- 
tions of  the  skin,  disease  in  the  bones  or  joints,  and  catarrh  of  the 
mucous  membranes,  are  thus  given  by  Sir  William  Savory,  who 
speaks  of  two  chief  forms  of  the  diathesis  : — "  In  the  first,  dis- 
tinguished as  the  sanc^^uineous  or  serous,  there  is  a  general  want 
of  muscular  development ;  for  although  the  figure  may  be  some- 
times plump  and  full,  the  limbs  are  soft  and  flabby;  the  skin  is 
fair  and  thin,  showing  the  blue  veins  beneath  it ;  the  features  are 
very  delicate  ;  often  a  brilliantly  transparent  rosy  color  of  the 
cheeks  contrasts  strongly  and  strikingly  with  the  surrounding 
pallor  ;  the  eyes,  grey  or  blue,  are  large  and  humid,  with  sluggish 
pupils  sheltered  by  long  silken  lashes ;  hair  fine,  blonde,  auburn, 
or  red  ;  teeth  white  and  often  brittle  ;  there  is  frequendy  a  ful- 
ness of  the  upper  lip  and  alse  nasi ;  the  ends  of  the  fingers  are 
commonly  broad,  with  convex  nails  bent  over  their  extremities. 
Such  persons  usually  possess  much  energy  and  sensibility,  with 
elasticity  and  buoyancy  of  spirits ;  they  often  possess,  too,  con- 
siderable beauty.  In  this  variety,  with  the  same  delicacy,  the 
skin  and  eyes  are  sometimes  dark.  In  the  second,  distinguished 
as  the  phkgina/ic  or  melancJwlic,  the  skin,  pale  or  dark,  is  thick, 
muddy,  and  often  harsh,  the  general  as])ect  dull  and  heavy  ;  hair 
dark  and  coarse ;  the  mind  is  often,  but  not  always,  slow  and 
sluggish.  Children  especially,  in  whom  the  diathesis  is  strongly 
marked,  are  often  distinguished  by  the  narrow  and  prominent 


SYPHILIS.  65 

chest,  the  tumid  and  prominent  abdomen,  and  the  pastedike 
complexion ;  the  hmbs  are  wasted ;  the  circulation  languid ; 
chilblains  are  common  on  the  extremities ;  the  mucous  mem- 
branes particularly,  and  above  all  of  them  the  digestive,  are  liable 
to  morbid  action  ;  the  breath  is  often  sour  and  foetid  ;  the  tongue 
is  furred,  and  the  papillae  towards  the  apex  red  and  prominent ; 
the  bowels  act  irregularly,  and  the  evacuations  are  unusually 
offensive  ;  the  digestion  weak ;  the  appetite  variable  and  capri- 
cious." 

An  account  of  the  lesions  of  the  skin,  mucous  membranes,  ton- 
sils, lymphatic  glands,  bones,  joints,  testis,  &c.,  which  were  re- 
garded by  the  older  pathologists  as  local  symptoms  of  struma,  but 
are  now  generally  beheved  to  be  due  to  tubercular  infection,  is 
given  in  the  section  on  Diseases  of  Regions. 

SYPHILIS, 

Syphilis  may  be  divided  into  i,  the  acquired,  and  2,  the  in- 
herited or  congenital. 

Acquired  syphilis  is  a  constitutional  disease  due  to  direct 
inoculation  with  a  specific  virus.  It  is  characterized  by  the  ap- 
pearance, after  a  certain  period  of  incubation  during  which  the 
poison  is  circulating  in  the  system,  of  a  local  lesion  at  the  seat  of 
inoculation,  followed  by  induration  of  the  nearest  lymphatic 
glands,  and  after  a  variable  time  by  certain  affections  of  the  skin 
and  mucous  membranes  and  more  rarely  of  the  deeper  tissues, 
and  still  later  by  fibroid  changes  in  the  tissues  and  viscera,  or  the 
formation  of  gummata  which  are  exceedingly  hable  to  break 
down  and  suppurate. 

General  outline  of  the  disease. — Beyond  perhaps  a  slight 
abrasion,  which  heals  in  a  few  days,  and  is  possibly  thought  no 
more  of,  nothing  is  probably  noticed  till  about  three  weeks  to  a 
month.  Attention  is  then  called  to  the  part  by  a  shght  irritation, 
and  a  red  papule  may  be  noticed  which  slowly  enlarges,  becomes 
indurated  at  the  base,  and  perhaps  ulcerates.  This  papule  or 
ulcer  is  called  the  primary  chancre,  and  the  period  which  inter- 
venes between  the  date  of  inoculation  and  its  appearance  the 
period  of  incubation.  The  induration  of  the  sore  increases,  and 
the  neighboring  glands  become  hard  and  shotty.  In  from  six 
weeks  to  three  months  from  the  date  of  inoculation,  affections  of 
the  skin  and  mucous  membrane  ^egin  to  show  themselves,  and 
are  known  as  secondary  manifestations.  The  period  between 
their  appearance  and  the  induration  of  the  chancre  is  sometimes 
called  the  secondary  incubative  period,  during  which  time  malaise, 
pain  in  the  limbs,  lassitude,  etc.,  are  noticed.  The  secondary 
affections  are  symmetrical,  and  though  generally  confined  to  certain 
3* 


66  GENERAL  PATHOLOGY    OF   SURGICAL   DISEASES. 

superficial  changes  in  the  skin  and  raucous  membrane,  at  times 
attack  the  deeper  structures,  as  the  bones,  iris,  etc.  The  second- 
ary stage  may  last  from  two  months  to  two  years,  and  no  further 
changes  may  manifest  themselves,  the  disease  appearing  to  be 
worn  out ;  or  after  a  few  months  or  years  of  apparent  cure, 
further  changes,  known  as  tertiary  symptoms,  may  make  their 
appearance.  The  tertiary  affections  are  asymmetrical,  and  not 
only  attack  the  superficial  parts,  but  are  especially  common  in  the 
deeper  structures,  as  the  bones,  periosteum,  and  viscera.  They 
consist  in  the  formation  of  gummatous  material  in  the  skin  and 
mucous  membrane,  which  is  very  prone  to  break  down  and  ulcer- 
ate ;  and  of  gummatous  swellings  in  the  bones,  periosteum,  and 
viscera,  leading  to  suppuration,  fibroid  changes,  necrosis,  serious 
contractions,  paralysis,  etc.  The  tertiary  affections  may  last  for 
years  or  even  for  life,  and  not  infrequently  terminate  fatally  when 
involving  vital  structures.  It  should  be  thoroughly  understood, 
however,  that  there  is  no  hard  and  fast  line  between  the  second- 
ary and  tertiary  stages  of  syphilis.  The  one  may  merge  into  the 
other,  or  the  secondary  symptoms  may  last  into  the  period  usually 
assigned  to  the  tertiary,  whilst  the  latter  may  show  themselves  a 
few  months  after  the  first  appearance  of  the  sore.  Syphilis,  like 
the  exanthemata,  as  a  rule  confers  immunity  upon  the  patient 
from  a  second  attack,  although  in  rare  instances  a  second  attack 
has  been  known  to  occur.  As  long  as  the  patient  shows  second- 
ary manifestations  of  syphihs,  it  will  probably  be  transmitted  to 
any  offspring.  Hence,  as  a  rule,  a  patient  should  not  be  allowed 
to  marry  for  fully  two  years  after  the  disappearance  of  the  second- 
ary symptoms. 

Primary  syphilis. — The  primary  or  infecting  chancre,  or  hard 
sore  as  it  is  sometimes  called,  though  most  often  met  with  on  the 
genitals,  may  occur  on  any  part  of  the  body  exposed  to  infection, 
and  hence  is  not  infrequent  on  the  fingers  of  accoucheurs,  the 
lips,  nipple,  etc.  On  the  genitals  its  most  frequent  situation  is 
on  the  prepuce  just  behind  the  corona  glandis  in  the  male,  and 
on  the  inner  surface  of  the  labia  in  the  female ;  but  it  is  often 
met  with  on  the  glans,  the  skin  of  the  penis,  and  just  within  the 
urethra  :  more  rarely  on  the  vaginal  walls  and  os  uteri.  It  is 
commonly  produced  by  direct  contact  with  another  chancre,  or  a 
mucous  tubercle  or  other  secondary  lesion  ;  but  it  may  also  be 
contracted  indirectly  in  mari^  ways,  as  by  drinking  out  of  an 
infected  vessel,  or  by  inoculation  with  infected  lymph  in  vaccina- 
tion. The  exact  nature  of  the  virus  is  not  known,  but  is  believed 
by  many  to  be  a  specific  form  of  bacillus.  It  is  probable  that  it 
is  generally  inoculated  through  a  crack  or  abrasion,  except  in 
situations  where  the  skin  or  mucous  membrane  is  very  thin  and 


PRIMARY    SYPHILIS.  67 

delicate.  The  period  of  incubation  varies  from  ten  days  to  six 
or  seven  weeks,  or  even  longer.  When,  however,  the  syphilitic 
virus  is  inoculated  in  the  pure  state,  it  usually  gives  rise  to  no  sign 
till  three  to  five  weeks,  when  a  small  papule  will  be  noticed, 
which  enlarges  and  becomes  indurated  at  the  base,  and  may 
either  remain  as  an  indurated  nodule  throughout,  or  if  irritated 
change  into  a  small  ulcer.  Not  infrequently,  however,  the  virus 
may  be  conveyed  in  the  pus  of  a  non-infecting  or  soft  chancre, 
under  which  circumstances  a  soft  chancre  will  form  in  two  or 
three  days,  whilst  the  syphilitic  poison  is  still  circulating  in  the 
system,  and  after  the  incubative  period  is  passed  will  manifest 
itself  locally  by  induration  about  the  base  of  the  soft  sore,  or,  if 
this  is  healed,  by  an  indurated  nodule  at  its  former  site.  The 
characters  of  an  infecting  chancre  vary.  In  the  typical  form 
{^Hunterian  chancre),  it  is  raised  though  slightly  depressed  at  its 
centre,  whilst  its  surface  is  either  glazed  or  covered  with  epithelial 
debris  or  scanty  secretion ;  there  is  scarcely  any  inflammation, 
but  marked  and  sharply  circumscribed  induration  about  its  base. 
The  induration,  however,  may  be  absent  in  chancres  on  the  glans 
penis  and  on  the  female  genitals,  and  is  seldom  well  marked  in 
chancres  on  parts  of  the  body  other  than  the  genitals.  It  must 
be  borne  in  mind,  moreover,  that  a  non-infecting  sore  when 
inflamed  may  be  attended  with  some  inflammatory  induration, 
and  hence  may  be  mistaken  for  an  infecting  sore.  This  inflam- 
matory induration,  however,  is  diffused,  and  fades  away  into  the 
surrounding  parts ;  whereas  the  induration  of  an  infecting  sore 
feels  as  if  a  piece  of  cartilage  or  parchment  had  been  inserted 
under  the  skin.  Infecting  chancres,  though  usually  single,  may 
be  multiple  if  several  spots  are  inoculated  at  the  same  time,  all 
then  appearing  at  the  same  stage  of  development ;  but  when  a 
primary  chancre  has  once  declared  itself,  showing  that  the  system 
is  impregnated  with  the  poison,  other  chancres  can  no  longer  be 
produced  by  inoculation  in  the  same  patient.  The  duration  of  a 
primary,  chancre  varies.  It  usually  disappears  quickly  under  the 
influence  of  mercury,  but  if  untreated  may  last  for  many  months. 
The  lymphatic  glands  generally  become  enlarged  about  the  same 
time  as  the  induration  of  the  primary  sore,  a  condition  known  as 
indurated  bubo.  Thus,  if  the  chancre  is  on  the  genitals  or  about 
the  anus,  the  inguinal  glands  are  those  affected ;  if  on  the  finger, 
the  epitrochlear  or  axillary ;  if  on  the  lip,  the  submaxillary. 
They  have  a  hard,  shotty  feel,  remain  distinct  from  each  other, 
are  painless,  not  adherent  to  the  skin,  and  do  not,  as  a  rule, 
suppurate.  The  induration  is  commonly  greater  in  the  inguinal 
glands  than  in  those  of  other  situations ;  but,  at  the  same  time, 
the   enlargement  is  not  so  marked.     The  induration  may  subse- 


68  GENERAL   PATHOLOGY   OF    SURGICAL   DISEASES. 

quently  affect  all  the  glands  of  the  body,  especially  the  posterior 
chain  in  the  neck.  If  the  chancre  is  irritated  or  inoculated  with 
pus  from  a  soft  chancre,  or  a  soft  chancre  has  formed  simultane- 
ously, then  a  suppurating  bubo  may  occur. 

Secondary  syphilis. — The  secondary  symptoms  consist  of  cer- 
tain affections  of  the  skin  and  mucous  membranes,  general  enlarge- 
ment of  the  lymphatic  glands,  and  more  rarely  of  inflammation  of 
such  deeper  structures  as  the  iris  and  periosteum.  They  generally 
set  in  from  six  weeks  to  three  months  after  the  appearance  of  the 
primary  sore.  They  may  assume  a  very  severe,  or  a  very  mild 
form,  or  they  may  not  occur  at  all,  or  may  be  so  slight  as  to  be 
overlooked. 

The  ski7i  eruptions  may  take  various  forms.  The  earliest  to 
appear  is  usually  a  roseoious  rash  over  the  chest  and  abdomen. 
It  is  generally  accompanied  by  a  congested  condition  of  the 
mucous  membrane  of  the  fauces,  giving  rise  to  a  slight  sore 
throat.  This  rash  is  produced  merely  by  local  congestion,  and 
hence  fades  on  pressure  and  usually  disappears  in  a  short  time. 
But  should  the  congestion  continue,  some  infiltration  of  the  skin 
may  occur,  and  the  epithelium  take  on  increased  growth,  and  be 
thrown  off  in  the  form  of  scales,  the  eruption  being  then  known 
as  a  scaly  syphilide  or  psoriasis.  Should  further  infiltration  occur, 
a  papular  syphilide,  or  lichen,  may  be  produced  ;  or  if  the  pro- 
cess is  more  acute,  serum  may  be  exuded,  and  raise  the  cuticle  in 
the  form  of  small  vesicles,  or  even  of  large  blebs,  conditions  which 
are  spoken  of  as  a  vesicular  syphilide  or  eczema,  and  as  a  bullous 
syphilide  or  pemphigus  respectively.  Both,  however,  are  rare, 
and  the  latter  seldom  occurs,  except  in  congenital  syphilis.  Still 
later,  especially  where  the  patient  is  debilitated,  the  vesicles  may 
be  converted  into  pustules  (pustular  syphilide),  while  the  pustules 
again  may  dry  into  scabs,  which  fall  off,  leaving  no  scar  beneath 
{syphilitic  ecthyma)  ;  or  if  the  patient  is  cachectic,  or  his  constitu- 
tion broken  down,  ulceration  may  ensue  beneath  the  scabs 
{rupia).  Ihe  appearance  presented  by  rupia  is  pecuHar.  As 
the  ulceration  proceeds  in  depth  and  extent,  larger  and  larger 
scabs  are  successively  formed  beneath  those  above,  which  are  thus 
pushed  forward,  giving  the  mass  the  appearance  of  a  limpet-shell. 
Each  rupial  spot  is  surrounded  by  a  dusky-red  areola,  and  on  the 
separation  of  the  scab,  a  foul  circular  ulcer  is  left,  which,  on  heal- 
ing, leaves  a  permanent  scar.  Rupia  by  some  is  regarded  as  an 
early  tertiary,  by  others  as  a  late  secondary,  affection.  With  the 
exception  of  rupia  the  eruptions  in  syphilis  resemble  those  due  to 
non-syphilitic  causes.  They  are,  however,  all  modified  by  their 
coppery  or  raw  ham  color,  by  more  or  less  surrounding  pigmenta- 
tion, by  their  symmetrical  arrangement,  by  the  circular  or  cre.s- 


SECONDARY    SYPHILIS.  69 

centic  shape  of  the  patches,  by  the  absence  of  itching,  by  the 
absence  of  the  large  sih'ery  scales  seen  in  the  ordinary  psoriasis, 
by  their  predilection  for  certain  situations — /.  e.,  the  chest  and 
abdomen,  the  space  between  the  shoulders,  the  back  of  the  neck, 
the  forehead,  especially  about  the  roots  of  the  hair,  the  palms  and 
soles,  and  the  flexor  aspect  of  the  limbs ;  and  lastly,  by  their 
polymorphism — /.  e.,  their  mixed  character,  the  eruption  being 
here  papular,  here  scaly^  here  pustular,  etc.  In  situations  where 
the  parts  are  moist,  as  about  the  mouth,  anus,  and  scrotal  folds, 
the  papillae  become  succulent  and  the  epithelium  sodden,  forming 
condylomata.  Where  such  occur  between  the  toes,  ulceration 
may  ensue  {j'hagades)  ;  but  this  condition  is  not  common,  except 
as  the  result  of  uncleanliness.  Condylomata  appear  as  low,  soft, 
flattened,  sesile  elevations  of  a  whitish  color,  with  a  smooth  sur- 
face, covered  by  a  moist  secretion,  and  often  of  considerable 
size.  They  are  intensely  contagious,  and  when  occurring  where 
two  skin  surfaces  are  in  contact,  as  about  the  anus  and  labia,  are 
usually  symmetrically  placed  on  either  side.  The  affections  of  the 
mucous  membrane  are  similar  to  those  of  the  skin,  and  are  also 
usually  symmetrical.  At  first,  they  consists  of  mere  congestions, 
later  of  infiltrations  with  overgrowth  and  soddening  of  the  epithe- 
lium {mucous  tubercles),  and  subsequently  of  superficial  ulcera- 
tions from  the  breaking  down  of  the  infiltrating  inflammatory 
exudation.  Mucous  tubercles  are  especially  common  about  the 
palate  and  fauces,  side  of  the  tongue,  hps  and  cheek,  and  appear 
as  slightly  elevated  whitish-looking  patches,  giving  the  part  some- 
what the  appearance  of  having  been  rubbed  over  with  nitrate  of 
silver.  The  ulcers,  which  occur  in  similar  situations,  particularly 
about  the  tonsils  and  corners  of  the  mouth,  are  usually  of  a  cres- 
centic  shape,  with  sharp-cut  edges,  and  are  quite  superficial. 
Similar  mucous  patches  and  ulcers  may  occur  in  the  larynx  or 
about  the  anu-s  or  in  the  rectum. 

During  the  later  secondary  stages,  besides  the  superficial  erup- 
tions and  ulcerations  which  may  still  be  present,  the  deeper  struc- 
tures may  become  involved.  Amongst  these  may  be  mentioned 
the  iris,  periosteum,  bones«  joints,  ear,  and  testicle.  The  lym- 
phatic glands,  not  only  those  nearest  to  the  primary  sore,  but 
over  all  the  body,  become  affected,  the  posterior  cervical  more 
particularly  so.  This  condition  is  of  service  in  diagnosis  ;  but  as 
it  gives  rise  to  no  symptoms,  it  is  generally  overlooked  by  the 
patient.  Syphilitic  iritis  is  especially  characterized  by  the  presence 
of  nodules  of  lymph  on  the  iris,  the  effusion  into  the  anterior 
chamber,  the  comparatively  small  amount  of  pain,  and  its  amena- 
bility to  mercurial  treatment.  But  the  irregular  pupil,  discolored 
iris,  circumcorneal  zone  of  congestion,  photophobia,  and  patches 


70"  GENERAL  PATHOLOGY    OF   SURGICAL   DISEASES, 

of  pigment  on  the  lens,  are  also  present  as  in  other  forms  of  iritis. 
Th.t  periosiiiis  seldom  gives  rise  to  the  distinct  nodes  so  common 
in  the  tertiary  stage  ;  otherwise  the  symptoms  are  similar.  The 
joirit-affections  are  like  those  in  rheumatism,  and  exhibit  nothing 
very  characteristic.  Epididymitis  and  orchitis  are  occasionally 
observed,  and  are  then  generally  symmetrical,  thus  differing  from 
the  gummatous  affections  of  the  testicle  in  the  tertiary  stage. 

The  general  health  usually  suffers,  the  hair  becomes  thin 
{^syphilitic  alopecia),  and  the  patient  anaemic.  At  times  severe 
cachexia  ensues,  attended  by  much  wasting  and  prostration. 

Tertiary  syphilis. — The  symptoms  of  the  tertiary  stage  com- 
monly occur  after  a  period  of  apparent  cure,  sometimes  within  a 
few  months  after  the  cessation  of  the  secondary  symptoms,  at 
other  times  not  till  after  many  years.  Occasionally,  however,  they 
may  be  manifested  within  a  few  months  of  the  primary  sore,  i.  e., 
during  the  period  usually  assigned  to  the  secondary  stage.  More- 
over, between  the  termination  of  the  secondary  and  the  onset  of 
the  tertiary,  certain  skin  eruptions,  enlargements  of  the  testicle, 
choroiditis,  inflammations  and  ulcerations  of  the  tongue,  and 
psoriasis  of  the  palms  may  occur,  and  have  been  spoken  of  as 
"reminders."  They  are  by  some  regarded  as  constituting  an  in- 
termediary stage.  The  tertiary  affections  proper  are  of  a  more 
serious  nature  than  the  secondary,  and  show  no  tendency  to 
spontaneous  cure.  They  depend  upon  chronic  inflammations  in 
various  tissues  and  organs  leading  to  the  formation  of  granulation- 
tissue  {gu?n7}iata).  The  gummata  may  undergo  caseation  and 
break  down,  producing  when  situated  in  the  subcutaneous  and 
submucous  tissue  characteristic  ulcers  ;  or  they  may  continue  for 
indefinite  periods,  or  be  slowly  absorbed  under  appropriate  treat- 
ment, leaving  fibroid  thickenings  and  scarrings  in  the  capsules 
and  substance  of  the  affected  organs.  These  gummata  vary  in 
size  from  a  pea  to  a  walnut,  and  are  intimately  blended  with  the 
surrounding  tissues.  They  consist,  roughly,  of  three  zones ;  in 
the  central,  the  cells  are  breaking  down  and  undergoing  fatty 
change ;  in  the  next  zone  the  cells  are  contained  in  a  fibrillated 
matrix ;  in  the  outer  zone  numerous  vessels  ramify  among  the 
cells.  The  breaking  down  of  the  central  portion  is  attributed  to 
changes  in  the  vessels  causing  a  diminution  of  their  calibre  or 
complete  thrombosis,  whereby  the  blood-supply  of  the  central 
zone  is  cut  off  and  degeneration  consequently  ensues.  Amongst 
the  most  common  of  the  tertiary  lesions  may  be  mentioned — i, 
chronic  gummatous  inflammation  of  the  periosteum  and  bones, 
leading  to  the  formation  of  nodes,  caries,  or  necrosis,  and  giving 
rise,  as  when  attacking  the  bones  of  the  nose,  to  horrible  deform- 
ity ;  2,  gummatous  infiltration  of  the  skin  and  mucous  membrane 


TERTIARY   SYPHILIS.  7 1 

{tubercular  sypliilide)  terminating  in  serpiginous  ulceration;  3, 
gummatous  swellings  in  the  subcutaneous  and  submucous  tissue, 
which  may  break  down,  forming  deep  ulcers  the  cicatrization  of 
which  causes  severe  contractions,  as  for  instance  those  seen  in 
stricture  of  the  pharynx,  glottis,  and  rectum ;  4,  gummata  in  the 
muscles  ;  5,  gummata  in  the  tongue,  producing  scarring  and  ulcers 
apt  to  terminate  in  epithelioma ;  6,  affections  of  the  nervous  sys- 
tem leading  to  paralysis  ;  7,  affections  of  the  arteries  leading  to 
embolism  or  aneurysm ;  and  8,  gummata,  followed  by  contraction 
and  fibroid  changes  in  the  liver,  lungs  and  other  viscera.  The 
various  tertiary  lesions  will  be  further  described  under  Diseases 
of  the  special  Tissues  and  Organs ;  for  those  affecting  the  lungs, 
liver,  kidneys,  and  nervous  system,  a  work  on  Medicine  must  be 
consulted.  Here  it  must  suffice  to  say  that  the  tertiary  lesions  are 
usually  asymmetrical ;  that  they  are  not,  as  a  rule,  contagious ; 
that  they  are  chronic  in  their  course  ;  and  that  they  often  prove 
fatal  by  affecting  important  organs,  as  the  lungs  or  brain,  or  by 
causing  constriction  of  a  passage,  as  the  larynx  or  rectum. 

The  treatment  of  syphihs  necessarily  varies  according  to  the 
constitutional  condition  of  the  patient  and  the  stage  of  the  dis- 
ease. The  primary  sore  requires  no  other  local  treatment  than 
the  application  of  iodoform  or  black-wash  and  protection  from 
irritation.  Some,  however,  still  advocate  its  destruction  by  caus- 
tics or  complete  excision,  and  further  recommend  removal  at  the 
same  time  of  the  nearest  indurated  glands.  The  majority  of  Sur- 
geons have  regarded  such  treatment  as  useless,  believing  that  the 
induration  of  the  primary  sore  is  merely  an  indication  that  the 
disease  is  already  established  in  the  constitution.  Moreover,  ex- 
cision has  repeatedly  failed  to  prevent  the  occurrence  of  second- 
ary symptoms.  At  the  International  Medical  Congress  at  Berlin, 
however,  the  consensus  of  opinion  was  in  favor  of  the  possibility 
of  aborting  the  disease  by  an  early  excision.  Constitutionally, 
mercury  in  some  form  is  by  the  majority  of  Surgeons  thought  to 
be  necessary  in  all  cases.  It  must,  however,  be  given  with  caution 
to  strumous  and  tuberculous  subjects,  and  to  persons  whose  con- 
stitution is  impaired  by  dissipation,  alcohol,  or  bad  living.  It 
should  be  withheld  in  chronic  Bright's  disease  ;  nor  should  it  be 
forgotten  that  some  patients  exhibit  a  peculiar  idiosyncrasy,  in 
that  they  are  violently  salivated  by  a  grain  or  two  of  the  drug. 
Mercury  may  be  given,  i,  by  the  mouth  ;  2,  by  inunction ;  3,  by 
fumigation ;  and  4,  by  subcutaneous  injection.  It  is,  as  a  rule, 
perhaps,  best  given  by  the  mouth,  either  in  the  form  of  a  pill  or 
mixture.  As  a  pill,  the  green  iodide  in  doses  of  ^4  a  grain  to  2 
grains,  combined  with  yk  to  yi  of  a  grain  of  opium  to  prevent 
purging,  may  be  given  two  or  three  times  a  day,  or  the  mercury 


72:  GENERAL   PATHOLOGY    OF   SURGICAL    DISEASES. 

and  chalk  powder  in  doses  of  from  2  to  3  grains,  or  calomel  or 
blue-pill  may  be  substituted  for  it.  As  a  mixture,  the  perchloride 
in  doses  of  3V  to  iV,  of  a  grain,  combined  with  ammonia,  is  very- 
useful.  The  green  iodide  possesses  an  advantage,  in  that  the 
iodine  prevents  an  accumulation  of  mercury  in  the  system. 
Tannate  of  mercury  is  highly  recommended  by  some  Suigeons, 
since,  being  unaffected  by  dilute  acids,  it  passes  through  the 
stomach  without  change,  but  on  reaching  the  duodenum  is  re- 
duced by  the  alkaline  secretions  to  its  metallic  state,  the  globules 
being  so  minute  that  they  are  believed  to  be  capable  of  absorption 
by  the  villi.  Hence,  it  is  less  liable  than  other  preparations  to  set 
up  gastro-enteritis  and  diarrhcea,  and  having  no  cumulative  pro- 
perties there  is  less  fear  of  sahvation.  It  is  rapidly  absorbed  and 
as  quickly  eliminated  by  the  urine.  The  drug,  moreover,  is  stable. 
It  should  be  given  in  the  form  of  a  pill  in  doses  of  gr.  lyz.  Where 
mercury  given  by  the  mouth  causes  much  irritation  of  the  bowels, 
it  may  be  used  in  the  form  of  an  inunction,  half  a  drachm  to  one 
drachm  of  mercurial  ointment  being  rubbed  into  the  inner  part 
of  the  thigh  or  the  axilla  night  and  morning,  the  parts  being 
thoroughly  washed  every  day  to  preA'ent  the  ointment  accumulat- 
ing in  the  sweat-ducts,  etc.  This  is  a  rapid  way  of  bringing  the 
patient  under  the  influence  of  the  drug,  as  is  also  fumigation  with 
calomel  or  other  preparation  of  mercury,  though  this  latter  method 
may  be  followed  b)'^  violent  salivation.  Subcutaneous  injection 
appears  to  possess  no  special  advantages  over  the  other  methods, 
except  perhaps  in  obstinate  tertiary  nerve  lesions,  and  is  apt  to 
cause  sores  or  abscesses  at  the  point  of  puncture.  The  prepara- 
tions commonly  injected  are  the  T^erchloride,  gr.  yg  to  }(,  the 
salicylate,  gr.  ly.  When  injected  with  liquid  paraiifin  as  the 
vehicle,  signs  of  pulmonary  embolism  have  been  observed.  The 
effects  of  the  mercury  should  be  judged  by  its  action  on  the 
primary  sore  and  secondary  affections.  Under  its  influence  the 
induration  of  the  sore  rapidly  disappears,  and  the  rash  fades.  It 
should  never  be  pushed  beyond  causing  a  slight  soreness  of  the 
gums,  the  formation  of  a  red  line  on  their  free  margin,  and  ten- 
derness on  biting.  Should  salivation  occur,  the  mercury  should 
be  immediately  stopped,  a  gentle  purgative  given,  the  mouth 
rinsed  with  a  gargle  of  chlorate  of  potash,  and  iron  taken  inter- 
nally. The  mercury  should  also  be  intermitted  for  a  few  weeks 
or  so  at  a  time  if  symptoms  of  depression  come  on.  During  the 
mercurial  course  the  patient  should  avoid  chills  and  abstain  from 
alcohol,  fresh  fruit,  and  food  lial)le  to  disturb  the  digestion  and 
set  up  diarrhaa.  The  mercurial  course  may  with  advantage  be 
continued  for  a  year  or  more,  and  on  its  termination  iron,  tonics, 
and  cod-liver  oil  should  be  given,  whilst  change  of  air  and  the 


CONGENITAL   SYPHILIS.  73 

baths  of  Aix-la-Chapelle  or  Harrogate  will  be  found  beneficial. 
If  mercury  cannot  be  taken  or  is  contra-indicated,  iodide  of 
potassium  with  a  tonic  treatment  may  be  tried.  During  the 
secondary  stages  mercury  should  still  be  continued  internally. 
Locally,  condylomata  are  best  treated  by  dusting  them  with  equal 
parts  of  calomel  and  oxide  of  zinc,  under  which  they  dry  up  very 
rapidly.  Mucous  tubercles  about  the  fauces  may  be  gargled  with 
black-wash  ;  superficial  cracks  and  ulcers  on  the  lips,  tongue,  etc., 
may  be  touched  with  a  strong  solution  of  nitrate  of  silver,  or  a 
lotion  of  bicyanide  of  mercury  or  chromic  acid.  Iritis  should  be 
energetically  treated  by  mercury,  or  if  this  is  already  being  given, 
the  dose  should  be  increased,  whilst  locally  atropine  should  be 
dropped  in  the  eye,  and  if  there  is  much  pain  and  the  congestion 
is  acute,  leeches  or  blisters  should  be  applied  to  the  temple.  In 
the  tertiary  stages  iodide  of  potassium  has  the  most  marked  effect. 
It  may  often  be  advantageously  combined  with  ammonia,  quinine, 
iron,  or  cod-liver  oil,  or  even  with  small  doses  of  mercury  if  the 
affection  proves  intractable.  If  badly  tolerated,  kola  chocolate 
may  be  given  with  it,  or  iodide  of  sodium  or  ammonium  substi- 
tuted for  it.  In  tertiary  nerve  lesions  intramuscular  injections  of 
perchloride  of  mercury  (gr.  i^)  or  of  salicylate  of  mercury  (gr. 
i^)  are  strongly  recommended.  The  injections  are  usually 
made  once  a  week  or  oftener  in  the  gluteal  region,  the  syringe 
being  passed  deeply  into  the  underlying  muscle.  The  treatment 
of  tertiary  syphilis  will  be  referred  to  more  in  detail  under  the 
Diseases  of  Tissues  and  Organs. 

Should  phagedena  occur,  it  must  be  energetically  treated  by 
the  continuous  hot  bath,  or  by  the  destruction  of  the  ulcer  with 
the  fuming  nitric  acid  or  acid  nitrate  of  mercury. 

Congenital  or  inherited  syphilis  is  syphilis  transmitted  to  the 
offspring  by  one  or  both  of  the  parents,  and  must  be  distinguished 
from  syphilis  contracted  by  the  infant  coming  in  contact  with  a 
chancre  on  the  genitals  during  birth,  which  would  be  a  case  of 
acquired  syphilis.  Cause. — The  poison  is  transmitted  through 
the  spermatozoa  of  the  father,  or  the  ovum  of  the  mother,  and  not 
by  direct  inoculation  and  the  formation  of  a  primary  chancre,  as 
in  the  acquired  form.  Symptoms. — The  child  is  usually  born 
healthy,  and  though  the  virus  is  present  in  the  system,  the  disease 
does  not  manifest  itself  as  a  rule  till  the  fourth  to  the  sixth  week. 
In  rare  instances,  however,  infants  are  born  with  well-marked 
signs  of  syphilis  ;  and  at  times  the  affection  does  not  show  itself 
till  much  later  in  life.  But  in  the  latter  case  the  symptoms  are 
those  of  the  tertiary  stage,  not  those  of  the  secondary  stage  de- 
layed. The  symptoms  in  a  typical  case  usually  set  in  with  a 
chronic  catarrh  of  the  nasal  mucous  membrane,  popularly  known 
4 


74  GENERAL   PATHOLOGY    OF   SURGICAL   DISEASES. 

as  the  snuffles,  followed  by  a  rash  on  certain  parts  of  the  body, 
and  mucous  tubercles  and  superficial  ulcerations  about  the  mouth 
and  anus.  The  catarrh  may  simulate  merely  a  cold  in  the  head, 
or  be  attended  with  a  muco-purulent  discharge,  and  cause  ob- 
struction to  respiration  and  difficulty  in  sucking.  The  eruption, 
hke  that  of  the  secondary  stages  of  acquired  syphilis,  is  symmet- 
rical, and  of  the  same  pecuhar  coppery  or  raw-ham  color.  It  is 
most  common  about  the  nates  and  genitals,  where  it  is  usually 
erythematous  in  character,  and  on  the  palms  of  the  hands  and 
soles  of  the  feet,  where  it  is  commonly  squamous.  But  it  may  be 
papular  and  at  times  bullous  or  pustular.  A  well-marked  mucous 
tubercle  or  condyloma  about  the  anus  is  pathognomonic  of  the 
disease.  These  symptoms  are  frequently,  though  not  invariably, 
accompanied  by  anaemia  and  wasting,  the  child  looks  shriveled 
and  old,  the  skin  earthy  and  dry,  whilst  the  hair  may  fall  off,  and 
the  nails,  iris,  periosteum,  and  the  bones  may  be  affected  as  in 
the  acquired  form.  At  this  period  death  is  far  from  uncommon. 
Usually,  however,  and  especially  under  a  mercurial  course,  the 
symptoms  gradually  subside,  and  by  the  end  of  the  first  year  dis- 
appear altogether  and  no  further  manifestation  of  the  disease  may 
occur  throughout  life.  But  frequently  after  several  years  of  im- 
munity certain  tertiary  affections  show  themselves,  the  chief  of 
these  being  interstitial  keratitis,  periostitis,  and  osteitis,  followed 
by  necrosis,  disease  of  the  ear  often  ending  in  total  deafness, 
ulceration  about  the  palate,  chronic  synovitis  of  one  or  more  of 
the  joints,  and  the  formation  of  gummata  in  the  viscera,  testicle, 
etc.  Along  with  these,  certain  important  diagnostic  symptoms, 
the  result  of  the  former  secondary  lesions,  may  be  present,  viz.,  i, 
a  depressed  and  widened  condition  of  the  bridge  of  the  nose, 
due  to  the  influence  of  the  nasal  catarrh  upon  the  development 
of  the  nasal  bones  and  septum ;  2,  radiating  scars  about  the 
angle  of  the  mouth,  the  result  of  the  cicatrization  of  the  former 
ulcers  {^Hutchinson's  lines)  ;  3,  a  peculiar  conformation  of  the 
skull,  the  result  of  the  previous  bone-lesion,  consisting  chiefly  in 
a  furrow  above  the  eyebrows,  a  square  forehead,  and  prominent 
frontal  eminences;  and  4,  a  characteristic  appearance  of  the 
permanent  central  incisor  teeth,  consequent  upon  the  action  of 
the  stomatitis  upon  them  while  yet  soft  and  uncut.  The  distinc- 
tive sign  of  syphilis  in  these  teeth  is  a  slight  crescentic  notch  in 
the  biting  edge  (Fig.  9).  They  are  also  generally  dwarfed, 
especially  in  width,  their  angles  are  rounded  off,  and  their 
sides  convex  in  outline  {pe^^gcd  teeth).  These  appearances 
must  be  distinguished  from  those  due  to  the  action  of  the 
mercurial  stomatitis,  the  teeth  so  affected  showing  horizontal 
markings,  or  honey-comb-like  excavations  in  the  enamel  (com- 
pare Figs.  9  and  10). 


CONGENITAL   SYPHILIS. 


75 


The  bone  lesions  of  congenital  syphilis  were  until  recently  over- 
looked or  confounded  with  those  of  rickets,  which  they  much  re- 
semble. Two  forms  are  described,  the  osteophyiic  and  the 
atrophic.  In  the  osteophytic  the  cranial  bones  present  localized 
and  symmetrical  thickenings  {Parrofs  nodes)  in  the  region  of 
the  frontal  and  parietal  eminences  i^tlie  natifo7'm  07-  hot-C7-oss-biin- 
/ike  skuil),  diud  the  long  bones  subperiosteal  enlargements.  In 
the  atrophic  the  cranial  bones,  especially  in  the  occipital  region, 
are  thinned  or  locally  absorbed,  so  that  the  brain  is  only  covered 
at  these  spots  by  a  thin  membrane  {osteoporosis  craniotabes,  and 
the  long  bones  are  enlarged  at  their  epiphyses  by  the  production 
of  ill-formed  bone  and  the  absorption  of  the  normal  bone.  These 
lesions  are  usually  transitory,  and  generally  give  rise  to  little  in- 


FiG.  g. 


Fig.  io. 


Syphilitic  teeth  (after  Hutchison). 


Mercurial  teeth  (after  Hutchison). 


convenience ;  but  at  times  separation  of  the  epiphysis  may  occur, 
with  inflammation  of  the  neighboring  joint ;  and  when  several 
bones  are  affected,  the  child  may  be  so  chary  of  movement  on 
account  of  the  pain  it  causes  that  infantile  paralysis  may  be 
simulated. 

Treatment. — In  the  early  stage  mercury  generally  acts  like  a 
charm.  It  is  best  administered  as  an  inunction  by  putting  half  a 
drachm  of  blue  ointment  on  the  binder  of  the  child  and  allowing 
it  to  be  thus  rubbed  into  the  skin.  Or  it  may  be  given  in  the 
form  of  mercury  and  chalk  in  doses  of  from  half  to  one  grain,  but 
is  then  apt  to  cause  diarrhoea.  Mercury,  however,  should  be 
given  with  caution  if  there  is  much  marasmus,  and  discontinued 
as  soon  as  the  symptoms  have  cleared  up.  lest  mercurial  stoma- 
titis be  induced  and  the  permanent  teeth  suffer  in  consequence 
(Fig.  lo).  The  child  should  be  well  and  carefully  fed  during 
the  mercurial  course,  and  small  doses  of  cod-liver  oil  may  often 
be  taken  with  advantage.  If  the  mother  is  unable  to  suckle  the 
infant  it  must  be  brought  up  by  hand,  not  by  a  wet-nurse,  for  fear 
of  her  nipple  becoming  affected  with  a  primary  chancre,  a  danger 
the  mother  herself  does  not  run,  even  although  she  has  exhibited 
no  signs  of  syphilis.     This  inabihty  of  an  infant  with   inherited 


76  GENERAL   PATHOLOGY    OF   SURGICAL   DISEASES. 

syphilis  to  infect  its  mother  (known  as  Colics''  laiu)  was  formerly 
thought  to  be  a  proof  that  the  mother  had  suffered  from  syphilis 
whilst  the  foetus  was  in  utero.  In  some  instances  this  has  no 
doubt  been  the  case ;  but  in  other  instances  she  has  shown  no 
sign  of  syphilis  during  gestation,  and  there  has  been  reliable  evi- 
dence that  she  had  not  had  the  disease  previously.  The  explana- 
tion offered  by  the  followers  of  M.  Pasteur  is  that  the  syphilis  of 
the  foetus  has  protected  the  mother. 

In  the  later  stages  of  congenital  syphilis,  as  in  those  of  the 
acquired  form,  iodide  of  potassium  is  indicated,  and  may  fre- 
quently be  advantageously  combined  with  small  doses  of  mercury, 
where  the  later  lesions,  as  is  too  often  the  case,  prove  intractable. 
Lastly,  should  syphilis  be  suspected  in  either  of  the  parents  during 
the  period  of  gestation,  mercury  should  be  administered  to  the 
mother  :  whilst  a  caution  should  be  given  to  both  parents  after 
the  birth  of  a  syphilitic  infant,  for  the  sake  of  any  future  offspring. 

H.TuMOPHILIA. 

H/EMOPHILIA,  or  the  haemorrhagic  diathesis,  is  a  condition  in 
which  bleeding  is  prone  to  occur  spontaneously  or  on  the  slightest 
provocation,  and  is  very  difficult  to  arrest.  The  cause  is  unknown. 
The  affection,  however,  appears  to  be  hereditary  ;  it  often  occurs 
in  members  of  the  same  family,  and  nearly  always  in  the  males, 
although  it  is  almost  invariably  transmitted  through  the  female 
line.  The  pathology  of  the  disease  is  obscure,  but  the  arteries 
have  been  found  thin,  the  left  ventricle  hypertrophied,  and  the 
different  forms  of  leucocytes  in  the  blood  relatively  altered  in 
number.  The  bleeding  may  be  started  by  the  most  trifling  in- 
jury, such  as  a  mere  scratch  of  the  finger,  the  extraction  of  a 
tooth,  or  a  bite  of  the  lip  or  tongue.  Or  it  may  occur  spontan- 
eously, when  it  is  sometimes  preceded  by  flushings  of  the  face  and 
throbbing  of  the  arteries,  and  then  commonly  takes  the  form  of 
epistaxis,  or  of  extravasations  beneath  the  skin,  or  of  bleeding 
from  the  gums  or  intestines,  or  of  effiision  into  a  joint.  When  the 
result  of  a  traumatism,  the  blood,  except  a  large  artery  is  wounded, 
oozes  from  the  injured  surface  in  a  steady,  continuous,  and  un- 
controllable stream.  The  bleeding  may  last  for  weeks  and  then 
cease  spontaneously,  leaving  the  patient  in  an  an?emic  condition, 
from  which,  however,  he  may  speedily  recover ;  or  it  may  termi- 
nate fatally.  Successive  attacks  are  common  at  varying  intervals, 
and  to  one  of  these  the  patient  generally  succumbs.  Should, 
however,  he  survive  the  period  of  puberty,  there  is  a  fair  chance 
of  the  tendency  to  bleed  decreasing  with  advancing  years.  The 
treatment  consists  in  ])lacing  the  patient  at  perfect  rest  in  the  re- 
cumbent position,  applying  a  graduated  compress,  and  in  elevating 


lUlMORS.  77 

the  part  when  the  bleeding  comes  from  a  limb.  Ligature,  the 
actual  and  galvanic  cautery  and  acupressure,  only  do  harm  by  in- 
creasing the  size  of  the  wound  ;  and  cold,  in  the  form  of  ice,  is  of 
doubtful  benefit.  When  the  blood  comes  from  a  tooth-socket  a 
plug  of  perchloride  of  iron  may  be  applied.  Internally,  such 
drugs  as  ergotin,  acetate  of  lead,  gallic  acid,  and  sclerotic  acid 
are  recommended,  but  do  not  appear  to  have  much  power  in 
controlling  the  bleeding.  Recently  calcium  chloride  (grains  lo 
to  15)  has  been  recommended  internally,  and  as  a  local  styptic  a 
solution  of  fibrin  ferment  to  which  calcium  chloride  has  been 
added  (see  Styptics,  p.  130).  Wright  has  found  that  the  internal 
use  of  chloride  of  calcium  in  a  case  of  haemophilia  reduced  the 
coagulation  time  from  10  to  5  seconds. 

TUMORS. 

A  TUMOR,  as  generally  understood,  is  a  swelling  not  depending 
upon  inflammation  or  mere  h}pertrophy  of  pre-existing  tissue, 
and  showing  no  tendency  to  undergo  spontaneous  cure  or  to  yield 
to  the  action  of  medicines.  In  structure  a  tumor  consists  of  ele- 
ments resembling  those  of  the  normal  tissues  of  the  body  either 
in  the  mature  or  in  the  immature  state.  Thus  a  tumor  may  be 
composed  of  bone,  cartilage,  fat,  etc. ;  or  of  cells  like  those  con- 
stituting the  epithelium  ;  or  of  elements  indistinguishable  from 
the  rudimentary  tissues  found  in  the  embryo.  A  tumor  may 
resemble  and  continue  to  grow  in  the  tissue  in  which  it  originates, 
merely  displacing  the  surrounding  tissues,  as  for  example,  a  fatty 
tumor  growing  in  the  subcutaneous  fat.  It  is  then  called  homolo- 
gous. Or  a  tumor  may  originate  in  one  tissue,  and  retaining  the 
type  of  that  tissue,  invade  another,  as  an  epithelioma  infiltrating 
connective  tissue,  muscle,  or  bone  ;  it  is  then  spoken  of  as  heter 
ologous.  Homologous  tumors  have  generally  the  structure  of  the 
mature  tissues  of  the  body,  as  fibrous  tissue,  fat,  bone,  etc.,  and 
are  usually  innocent.  Heterologous  tumors,  on  the  other  hand, 
commonly  consist  of  cells  like  those  of  the  more  lowly  organ- 
ized or  immature  tissues  {epithelium,  embryonic  tissue),  and  are 
generally  malignant.  The  lower  the  organization  of  a  tumor,  the 
greater  as  a  rule  is  its  malignancy,  although,  as  pointed  out  by 
Mr.  Butlin,  "tumors  of  similar  structure  differ  widely  in  their 
power  of  mischief,  according  to  the  part  of  the  body  in  which  they 
originate." 

Development. — All  tumors  are  believed  to  arise  by  the  multi- 
plication of  pre-existing  cells,  and  to  retain  throughout  their 
growth  the  type  of  the  cell  from  which  they  spring  ;  hence  they 
are  spoken  of  as  connective  tissue  or  as  epithelial  growths,  accord- 
ing as  they  originate  in  the  connective  tissue  or  in  the  epithelium.' 


78^  GENERAL   PATHOLOGY   OF   SURGICAL   DISEASES. 

Tumors  arising  in  the  connective  tissue  may  at  first  consist  entirely 
of  small  round  cells,  with  a  scanty  amount  of  intercellular  sub- 
stance ;  that  is,  they  resemble  young  connective  tissue.  They 
may  retain  this  structure  throughout  their  course  (sa/roma),  or 
they  may  become  more  highly  developed  and  assume  the  struc- 
ture of  the  more  specialized  connective  tissues.  Thus,  fibrifica- 
tion  may  occur  and  the  tumor  take  the  form  of  mature  fibrous 
tissue  {fibroma)  ;  or  chondrification  or  ossification  may  ensue,  or 
fat  be  deposited  in  the  cells,  and  the  tumor  become  indistinguish- 
able in  structure  from  normal  cartilage,  bone  or  fat  {enchondroma, 
osteoma,  lipoma).  Tumors  springing  from  epithelium  not  only 
retain  the  character  of  epithelium,  but  likewise  that  of  the  special 
form  of  epithelium  from  which  they  are  derived.  Thus  they  re- 
semble squamous  epithehum  when  derived  from  the  skin,  sphe- 
roidal epithelium  when  from  a  gland. 

Cause. — Little  is  actually  known  of  the  etiology  of  tumors. 
Some  forms,  however,  appear  undoubtedly  to  be  due  to  local 
causes,  such  as  i,  long  continued  irritation  ;  2,  chronic  inflamma- 
tion ;  and  3,  injury;  but  whether  these  conditions  are  in  them- 
selves capable  of  producing  tumors  unless  the  patient  is  otherwise 
in  some  unknown  way  predisposed  to  tumor- formation  is  still 
perhaps  open  to  question.  The  presence  in  the  completely  de- 
veloped tissues  of  embryonic  remains  which  from  some  un- 
explained cause  have  taken  on  active  growth  later  in  life,  is  also 
regarded  by  some  pathologists  as  a  cause.  The  question  however 
of  greatest  interest  at  the  present  time,  is  that  of  the  infective 
nature  of  the  cancers.  So  far  no  one  has  succeeded  in  inoculat- 
ing the  disease  from  man  to  animals,  nor  from  animal  to  animal 
of  the  same  species,  except  by  actually  grafting  a  portion  of  the 
growth,  and  no  specific  micro-organisms  of  the  nature  of  a  bacillus 
or  micrococcus  have  been  discovered  by  cultivation-experiments. 
In  the  epithelial  cells  of  the  carcinomata,  however,  peculiar 
bodies  have  been  found,  and  are  believed  by  their  discoverers  to 
be  of  the  nature  of  protozoa,  and  similar  to  the  psorosperms 
present  in  the  epithelial  cells  in'coccydiosis,  a  parasitic  disease 
of  rabbits.  Whether  these  bodies  are  of  the  nature  of  protozoa 
as  maintained  by  their  discoverers  is  open  to  dispute.  Some  of 
them  at  any  rate  thus  described  have  been  proved  to  be  de- 
generations of  the  epithelial  cells  or  degenerations  of  the  nuclei. 
The  arguments  for  and  against  the  view  of  the  parasitic  nature  of 
cancer  cannot  be  here  discussed.  Although  it  would  appear  that 
no  true  spores  have  as  yet  been  demonstrated  and  it  has  been 
proved  that  cancer  cannot  be  inoculated,  it  is  possible  that  the 
parasite,  if  such  exists,  may  need  for  its  further  development,  as 
do  the  protozoa  of  some  other  parasitic  diseases,  special  conditions 


TUMORS.  79 

outside  the  body  of  its  host.  The  fact  that  cancer  is  endemic  in 
certain  localities  seems  to  lend  ^ome  support  to  the  idea  that  it 
may  be  of  miasmo-parasitic  origin.  Mr.  D'Arcy  Power,  who  has 
been  doing  excellent  work  on  this  subject,  declares  himself  an 
unbeliever  in  any  of  the  cancer  bodies  which  have  yet  been  dis- 
covered, and  believes  his  experiments  show  that  they  are  merely 
the  result  of  chronic  inflammation  of  the  epithelium. 

Tumors  have  further  been  ascribed  to  such  constitutional  causes 
as  hereditary  predisposition,  the  activity  of  tissue-growth  in  early 
life,  the  slow  degeneration  of  advancing  age,  and  the  lessened 
resisting  power  of  the  tissues  that  may  be  occasioned  by  such  de- 
pressing influences  as  grief,  anxiety,  or  mental  strain.  Residence 
in  certain  localities  is  considered  by  some  observers  to  be  a  pre- 
disposing cause  of  soma  forms  of  malignant  tumor. 

Clinical  course. — Clinically,  tumors  are  spoken  of  as  innocent 
and  malignant.  I.  Innocent  tumors  as  a  rule  grow  slowly,  and 
resemble  the  fully-formed  tissues  of  the  body,  and  usually  those 
amongst  which  they  grow.  They  are  generally  encapsuled,  cir- 
cumscribed, and  freely  movable,  merely  displacing  the  tissues 
around,  not  infiltrating  them.  They  do  not  involve  the  lymphatic 
glands,  nor  become  disseminated  in  distant  organs;  neither  do 
they  recur  if  completely  removed.  They  may,  however,  attain  a 
large  size  and  destroy  Ufe  by  pressing  upon  a  vital  organ,  or  in 
other  ways  interfering  with  its  functions.  II.  Malignant  tumors, 
on  the  other  hand,  grow  rapidly,  do  not  resemble  the  fully-formed 
tissues  in  structure,  and  differ  markedly  in  appearance  from  the 
tissues  in  which  they  grow.  They  are  generally  non-encapsuled 
and  infiltrate  the  surrounding  parts,  whether  these  be  muscle,  fat, 
bone,  etc.,  and  in  consequence  become  more  or  less  fixed  and 
adherent.  They  frequently  involve  the  lymphatic  glands,  and 
become  disseminated  through  the  body  by  means  either  of  the 
lymph  or  blood-stream.  They  usually  recur  after  removal,  in  the 
scar,  in  the  corresponding  lymphatic  glands,  or  in  internal  organs, 
and  sooner  or  later  give  rise  to  a  general  cachectic  condition 
known  as  the  cancerous  cachexia.  Death  is  commonly 
due  to  exhaustion  caused  by  the  local  ulceration,  haemorrhage 
and  pain,  combined  with  the  mental  distress  and  the  general  in- 
terference with  nutrition  induced  by  the  rapid  growth  of  the 
tumor  and  its  dissemination  through  internal  organs. 

Secondary  changes  are  common  in  tumors,  especially  in  those 
of  more  rapid  growth.  Thus  a  tumor  may  become  inflamed,  or 
may  ulcerate,  or  undergo  fatty,  mucoid,  colloid,  pigmentary,  or 
calcareous  degeneration  ;  or  as  the  result  of  these  changes,  or  of 
haemorrhage  into  its  substance,  cysts,  or,  more  rarely,  circumscribed 
abscesses,  may  form  in  its  interior ;  or  the  whole  tumor  may 
undergo  necrosis,  and,  in  exceptional  instances,  slough  away. 


So  GENERAL    PATHOLOGY    OF    SURGICAL    DISEASES. 

Recurrence  and  dissemination. — Local  recurrence  is  probably 
the  result  of  some  of  the  tumor-elements  having  escaped  removal, 
and  may  take  place  in  the  scar,  or  in  the  tissues  immediately 
around.  Reproduction  in  the  neighboring  lymphatic  glands  is 
believed  to  be  due  to  the  tumor-cells  becoming  arrested  in  the 
lymph-sinuses;  dissemination  in  more  distant  tissues  and  organs 
to  the  tumor-cells  being  carried  by  the  blood-stream  (which  they 
may  enter  either  directly,  or  indirectly  by  the  lymph-channels) 
to  these  parts,  where  they  become  lodged  and  form  starting- 
points  for  secondary  growths.  Secondary  growths,  whether  in  the 
glands  or  elsewhere,  resemble  in  structure  the  primary  tumor. 

Classification. — Tumors  are  here  classified  according  to  their 
anatomical  structure.     Thus,  they  may  be  divided  into  : 

L  Connective-tissue  tnmors,  which  are  such  as  spring  from  the 
connective  tissue.  These  may  be  subdivided  into  :  A.  Those  of 
the  type  of  fully-formed  connective  tissue,  /.  e.,  fibrous,  cartila- 
ginous, fatty,  osseous,  and  mucous  tissue  :  (i)  Fibroma,  {2)  En- 
chondroma,  (3)  Lipoma,  (4)  Osteoma,  (5)  Myxoma,  (6)  Papil- 
loma. B.  Those  of  the  type  of  the  higher  complex  connective 
tissues,  /.  <?.,  muscle,  nerve,  blood-vessels,  lymphatic  vessels  and 
lymphatic  glands:  (i)  Myoma,  (2)  Netiroma,  (3)  Angioma, 
(4)  Lymphangioma,  d.nd  (5)  Lymphoma.  C.  Those  of  the  type 
of  young  connective  tissue:  (1)  Round-celled  sarcoma,  (2) 
Spindle-celled  sarcoma,  (3)   Myeloid  sarcoina. 

II.  Epithelial  and  glandular  tumors,  which  are  such  as  are 
composed  of  cells  like  epithelium.  They  are  divided  into  : — A. 
The  innocent:  (i)  Adenoma;  and  B.  The  malignant:  (i) 
Spheriodal-celled carcinoma  :  (a)  Hard,  scirrhous,  or  chronic  caj- 
cinoma,  (<5)  Soft  encephaloid,  or  acu,te  carcinoma ;  and  (^)  Col- 
loid carcinoma.  (2)  Squamous-celled  carcinoma  {epithelioma'), 
and  (3)  Columnar-celled  or  cylindrical  carcinofna. 

III.  Teratoma,  a  rare  form  of  tumor,  containing  bone,  hair, 
teeth,  or  fragments  of  the  viscera  of  a  suppressed  foetus. 

L    CONNECTIVE-TISSUE   TUMORS. 

A.   Tumors  of  the  type  of  fully-formed  connective  tissue. 

Fibromata  or  fibrous  tumors  consist  of  fibrous  tissue,  which 
may  vary  in  density  from  the  firmness  of  a  tendon  or  ligament  to 
the  soft  consistency  of  the  subcutaneous  tissue.  They  are  quite 
innocent,  grow  slowly,  do  not  return  if  completely  removed,  and 
are  usually  surrounded  by  a  distinct  capsule. 

Structure. — 7he  firmer  varieties  (Fig.  11)  consists  of  dense 
fibrous  tissue  intermixed  with  but  few  elastic  fibres  and  connective- 
tissue  corpuscles.     The  fibres,  as  a  rule,  fire  variously  interlaced 


FIBROUS    TUMORS. 


Fig 


Fibrous  tumor.     Firm  variety. 


without  definite  arrangement,  though  in  some  fibromata  they  form 
concentric  circles  around  the  blood-vessels.  On  section  they  ap- 
pear firm,  smooth,  and  glistening,  and  of  a  grayish -white  color. 
The  vessels  are  usually  small,  thin- 
walled,  and  not  numerous,  though 
certain  of  the  fibromata  {naso-phar- 
yngeal  polypi)  are  very  vascular,  and 
are  permeated  by  large  cavernous 
blood-spaces.  The  softer  varieties, 
formerly  called  fibro-cellular  tumors, 
consist  of  loose  succulent  fibrous  tis- 
sue, and  often  contain  large  and  nu- 
merous blood-vessels.  On  section 
they  appear  yellowiafti,  glistening, 
semi-transparent,  and  gelatinous,  and 
a  serous  fluid  can  be  squeezed  out 
from  the  cut  surface. 

Secondafj   changes. — Calcification, 
ulceration,  and  mucoid  softening. 

Usual  seats. — Fibromata  may  grow  from  the  connective  tissue 
anywhere,  but  the  harder  forms  are  chiefly  met  with  in  the  peri- 
osteum, especially  that  of  the  jaws  {fibrous  epulis),  in  the  uterus 
where  they  are  intermixed  with  unstriped  muscle  {viyo -fibroma), 
in  the  neurilemma  of  nerves  {false  neuroma'),  on  the  termination 
of  nerves  {painful subcutaneous  tumor),  and  in  the  naso-pharynx 
and  rectum  {fibrous  polypus).  The  softer  forms  grow  from  the 
subcutaneous  and  submucous  tissue,  and  the  intermuscular  septa, 
and  are  most  frequently  met  with  in  the  scrotum,  labium,  and 
scalp.  The  loose  textured,  large  and  often  pendulous  growths,  oc- 
curring in  the  subcutaneous  tissue,  and  known  as  7oens,  and  the 
small  sessile,  or  partially  pedunculated  tumors  scattered  over  the 
body  in  the  condition  known  as  vwlluscum  fibrosum,  are  varieties 
of  soft  fibromata. 

The  signs  and  diagnosis  of  fibromata  vary  according  to  their 
situation,  and  will  be  again  referred  to  under  the  diseases  of  the 
various  regions  in  which  they  occur.  The  firm  fibromata  are 
usually  oval  or  globular,  smooth,  painless  unless  attached  to  a 
nerve,  movable,  very  firm  and  hard,  and  generally  single.  The 
softer  forms  are  smooth,  globular,  elastic,  soft  and  painless,  espe- 
cially when  growing  about  the  scrotum  or  labium  ;  doughy,  non- 
elastic,  movable,  pendulous,  and  fleshy  when  occurring  as  wens. 

T7'eatment. — When  practicable  they  should  be  removed. 

LiPOMATA  OR  FATTY  TUiMORS  are  composcd  of  fat  like  that 
normally  found  in  the  body.  They  are  innocent,  and  grow  slowly, 
but  may  attain  a  large  size,  and  do  not  return  on  removal.  They 
are  most  common  in  adult  life, 


82  GENERAL   PATHOLOGY    OF   SURGICAL    DISEASES. 

Structure. — They  consist  of  masses  of  fat  bound  together  by 
deUcate  connective-tissue  and  blood-vessels,  and  are  surrounded 
as  a  rule  by  a  thin  capsule,  which  is  attached 
by  fibrous  septa   to    the    skin.     The    micro- 
scopical characters  are  seen  in  Fig.  12. 

Secondary  changes. — Mucoid  softening,  in- 
flammation with  adhesion  from  pressure,  and, 
very  occasionally,  ulceration  and  calcification. 
Usual  seats. — They  are  most  common  on 
the  shoulders,  back,  and  nates,  where  they 
have  been  attributed  to  irritation  or  pressure, 
Fatty  tumor.  as  by  the  braces,  the  sitting  posture,  etc. 

Signs  and  diagnosis.  They  form  circum- 
scribed, lobulated,  semi-fluctuating,  painless,  soft,  inelastic  tumors, 
generally  single,  but  occasionally  multiple.  They  may  be  distin- 
guished from  a  chronic  abscess,  a  bursa  or  a  cyst,  the  swellings  for 
which  they  are  perhaps  most  likely  to  be  mistaken,  by  the  edge 
shpping  from  under  the  fingers  when  the  side  of  the  tumor  is 
pressed  upon,  by  the  dimpling  of  the  skin  when  pinched  up 
between  the  thumb  and  fingers,  and  by  the  non-escape  of  fluid 
on  puncture  with  a  grooved  needle.  They  sometimes,  when 
gravity  favors  it,  shift  their  site  by  slipping  down  in  the  connective 
tissue.  This  is  most  common  in  the  spermatic  cord,  a  lipoma 
there  having  a  tendency  to  sink  down  into  the  scrotum.  A  diffuse 
variety  of  lipoma  is  sometimes  met  with  in  the  form  of  symmet- 
rical masses  of  fat  at  the  back  of  the  neck  and  below  the  chin. 
This  variety  is  mostly  seen  in  stout  men  above  middle  age,  and 
especially  in  those  who  are  addicted  to  alcohol. 

Treatment. — The  capsule  should  be  freely  opened,  when  the 
tumor  will  usually  readily  shell  out.  The  diffuse  form  should  be 
left  alone  ;  for  such,  liquor  potassse  in  small  doses  for  long  periods 
may  be  tried.  I  have  certainly  seen  these  tumors  get  smaller 
under  its  use. 

Enchondroma'ja,  or  cartilaginous  TUMORS  consist  of  cartilage, 
and  are  always  innocent,  grow  slowly,  and  do  not  return  on  re- 
moval. Cartilage,  however,  is  frequently  developed  in  sarco- 
matous tumors,  and  it  is  probable  that  the  malignancy  which 
enchondromata  have  at  times  apparently  exhibited  may  have 
been  due  to  the  presence  of  sarcoma  elements  which  were  over- 
looked. 

Structure. — Cartilaginous  tumors  are  generally  encapsulated, 
and,  when  large,  are  often  lobulated.  They  may  consist  of  a 
single  mass  of  cartilage,  without  visible  partitions,  or  of  numerous 
small  clustered  masses  bound  together  by  connective  tissue  and 
blood-vessels.      On    section    they    are    translucent,    bluish-grey. 


MUCOUS  TUMORS.  83 

pinkish-white,  homogeneous  or  coarsely  granular,  and  frequently 

mapped  out  into  irregular  lobules.    They  usually  consist  of  hyaline- 

or    fibro- cartilage.      The    microscopical 

characters  of   typical   examples   of    the  Fig.  13. 

hyaline  and  fibrous  varieties  are  seen  in 

Fig.  13. 

Secondary  changes. — Calcification,  ossi- 
fication, mucoid  softening  with  formation 
of  cysts,  and  ulceration. 

Usual  seats. — (i)  The  bones,  especi- 
ally the  phalanges  of  the  fingers  and 
sometimes  of  the  toes,  the  lower  end  of 
the  femur,  and  the  head  of  the  tibia  and 
humerus,    and    (2)    the    parotid    gland. 

Enchondromata    may    also    occur    m     the     Cartilaginous     Tumor.      Upper 
,         ,  ,.  1-j^i^i-i  half  hyaline;    lower  half  fib- 

subcutaneous  tissue  and  m  the  testicle.  rous. 

The  signs  and  diagnosis  will  be  given 
under  Tumors  of  Bone  and  Parotid  gland.  Here  only  need  it  be 
said,  that  their  chief  characteristics  are  their  extreme  hardness, 
smooth  or  lobulated  surface,  and  slow  growth.  They  are  usually 
single,  except  in  the  hands,  where  generally  several  fingers  are 
affected.  At  times  they  are  of  a  softer  consistency  in  places, 
owing  to  mucoid  softening,  and  at  times  of  rapid  growth,  but  in 
the  latter  case  it  is  probable  that  they  contain  sarcomatous  ele- 
ments. Although  they  may  occur  at  any  age,  they  are  most 
common  in  the  young. 

Treatment. — They  should  be  removed  where  possible. 

OsTEOMATA  OR  OSSEOUS  GROWJHS  consist  of  true  bone.  They 
very  rarely  occur  except  in  connection  with  bone  or  cartilage,  and 
will  again  be  referred  to  under  diseases  of  bone.  Those  growing 
in  connective  tissue  apart  from  bone  are  probably  other  tumors, 
or  structures  such  as  cysts,  tendons,  and  muscles,  that  have  un- 
dergone calcification  or  ossification. 

Myxomata  or  mucous  tumors  consist  of  tissue  resembling  that 
found  in  the  umbilical  cord  and  vitreous  humor  of  the  eye ;  but 
many  of  the  growths  that  were  formerly  claimed  as  myxomata 
would  appear  to  be  fibromata,  sarcomata  or  enchondromata  un- 
dergoing mucoid  softening.  Pure  myxomata  are  innocent  tumors 
and  do  not  return  if  completely  removed,  but  they  may  attain  a 
large  size. 

Structure. — They  consist  of  a  soft  gelatinous  semi-translucent 
material,  enclosed  in  a  loose  capsule  of  connective  tissue,  and  in- 
tersected by  bands  of  fibrous  tissue.  On  section,  they  are  of  a 
pinkish  or  yellowish-grey  color,  and  of  a  soft  gelatinous  consist- 
ency, often  almost  diffluent ;  whilst  a  tenacious  and   glairy  fluid- 


84 


GENERAL   PATHOLOGY    OF   SURGICAL   DISEASES. 


Fig.  14. 


INIyxomatous  Tumors. 


containing  large  quantities  of  mucin  oozes  away  from  the  cut  sur- 
face. Under  the  microscope  there  are  seen  round  and  spindle 
cells  and  stellate  cells  with  branching  processes,  the  processes 

forming  a  delicate  stroma  in  the 
meshes  of  which  the  homogeneous, 
gelatinous  basis-substance  is  con- 
tained (Fig.  14).  The  round  and 
spindle  cells  vary  in  number,  and 
are  not  shown  in  the  diagram. 
Fibrous  tissue,  fat,  cartilage,  and 
sometimes  adenomatous  and  sar- 
comatous elements  may  likewise  be 
present ;  but  it  is  questionable  in 
these  cases  whether  the  tumor 
should  not  be  regarded  as  a  soft 
fibroma,  lipoma,  enchondroma,  sar- 
coma, etc.,  undergoing  mucoid  degeneration. 

Secondary  Changes. — Fatty  degeneration,  inflammation,  ulcer- 
ation, and  the  formation  of  blood-cysts  owing  to  rupture  of  the 
capillary  vessels. 

Usual  seats. — They  are  most  often  found  in  the  nose,  where 
they  constitute  the  gelatinous  polypus.  They  are  also  found  in 
the  adipose,  subcutaneous,  submucous,  and  subserous  tis.sue,  and 
occasionally  in  the  periosteum  and  medulla  of  bone  and  neuri- 
lemma of  nerves. 

Signs. — Except  when  forming  polypi,  as  in  the  nose,  they  re- 
semble fatty  and  soft  fibrous  tumors,  from  which  they  cannot  be 
diagnosed  with  certainty.     The  so-called  gelatinous  or  mucous 
polypus  will  again  be  referred  to  under  Diseases  of  the  Nose. 
Tieatment. — Removal  where  practicable. 

Papillomata  or  warty  and  villous  tumors  resemble  in  structure 
the  papillae  of  the  skin  and  raucous  membrane.  They  include 
warts,  condylomata,  and  mucous  tubercles,  and  some  forms  of 
so-called  villous  tumors.  They  are  innocent  growths,  rarely  attain 
a  large  size,  and  only  occur  in  the  skin  and  mucous  membrane. 
In  old  people,  however,  warty  growths  are  apt  to  degenerate  into 
epitheliomata ;  and  villous  growths  in  the  bladder  may  destroy 
life  by  the  haemorrhage  to  which  they  frequently  give  rise. 

Structure. — They  all  agree  in  that  they  resemble  hypertrcfphied 
simple  or  compound  papilla.'.  Thus,  they  consist  of  several  layers 
of  connective  tissue  surrounding  one  or  more  central  blood-vessels, 
and  are  covered  by  one  or  many  layers  of  epithelium  resembling 
that  natural  to  the  part  from  which  they  spring.  The  epithelium, 
however,  never  penetrates  the  connective  tissue — a  point  that 
serves  to  distinguish  them  pathologically  from  epithelioma,  which 


WARTY   TUMORS.  85 

in  many  respects  they  resemble  in  structure.  The  warts  and  warty 
growths,  which  form  circumscribed  tumors  or  cauHflower-like 
masses  often  of  considerable  size,  consist  of  enlarged  papillae 
covered  with  several  layers  of  horny  epithehum,  and  contain  as  a 
rule  only  a  few  small  blood-vessels.  The  condylomata  and  mucous 
tubercles,  which  occur  as  flattened  elevations  of  the  skin  and 
mucous  membrane  respectively,  also  consist  of  enlarged  papilte, 
but  the  epithelium  covering  them  is  moist  and  sodden,  and  the 
connective  tissue,  as  might  be  expected  from  their  rapid  growth, 
is  abundantly  infiltrated  with  small  round  cells.  They  are  always 
the  result  of  syphilis.  The  viltous  tumors,  which  form  delicate 
branching  growths  resembling  the  villi  of  the  chorion,  are  also 
classed  by  some  pathologists  as  papillomata,  even  when  they  grow 
from  parts,  as  the  interior  of  the  bladder,  where  no  papillse  exist. 
In  such  situations  they  spring  from  the  sub-epithelial  connective 
tissue,  and  owe  their  papillary  shape  to  the  arrangement  of  the 
connective  tissue  and  epithelium  around  the  blood-vessels.  The 
latter  are  often  dilated  and  numerous,  and  frequently  give  way, 
leading  to  serious  haemorrhages.  The  epithelium  covering  them 
forms  a  deUcate  layer,  and  may  often  be  rubbed  off  or  washed 
away  by  the  urine. 

Usual  seats. — Papillomata,  in  the  form  of  warts  and  warty 
growths,  are  of  most  frequent  occurrence  in  the  skin,  especially 
of  the  hands  and  genital  organs,  and  in  the  larynx.  A.'i  condylo- 
mata and  mucous  tubercles,  they  occur  about  the  anus  and 
genitals,  and  on  the  mucous  membrane  of  the  mouth  and  throat. 
The  villous  growths  are  met  with  in  the  bladder,  rectum,  and 
larynx. 

Secondary  changes. — Pigmentation,  ulceration,  and  atrophy. 
As  age  advances,  the  epithelium  in  the  case  of  the  warty  growths 
is  liable  to  invade  the  underlying  connective  tissue,  the  papilloma 
being  thus  converted  into  an  epithelioma. 

The  signs,  diagnosis  and  treatment  of  the  different  varieties  of 
papillomata  are  given  under  the  heads  of  skin,  syphilis,  bladder, 
rectum,  and  larynx.  x-^ll  that  need  be  said  here  is  that  v.'arty 
growths,  especiallv  in  some  situations  as  about  the  genitals,  may 
greatly  resemble  epithelioma,  from  which,  however,  they  may  gen- 
erally be  distinguished  by  the  absence  of  induration  at  their  base, 
slower  growth,  non-impUcation  of  the  glands,  the  probable  his- 
tory of  venereal  disease,  and  by  their  occurrence  usually  at  an  age 
younger  than  that  at  which  epithelioma  is  commonly  met  with. 

B.    Tumors  of  the  type  of  the  higher  connective  tissues. 

The  myomata  or  muscle  tumors,  consisting  of  non-striated  or 
even  of  striated  muscular  fibres  ;  the  neuromata  consisting  of  true 


86  GENERAL   PATHOLOGY    OF    SURGICAL   DISEASES. 

nervous  tissue,  either  the  gray  or  the  white  ;  the  angiomata,  or 
ngevi ;  the  lymphangioniata,  consisting  of  dilated  lymphatics,  and 
the  lympho7nata  and  lymphadenomata,  consisting  of  lymphatic 
glandular  tissue,  will  receive  no  further  attention  here  (see  Ncsvi, 
Diseases  of  Nerves  and  Lymphatics).  Unstriped  muscle  tissue,  it 
may  be  said,  however,  is  frequently  found  in  the  so-called  fibroid 
tumors  iyinyo-fihroinata)  of  the  uterus,  of  which,  indeed,  it  often 
forms  the  chief  part.  It  is  also  found  in  the  chronically  enlarged 
prostate. 

C.  Tumors  of  the  type  of  young  connective  tissue  {Sarcomata). 

Sarcomata  constitute  a  group  of  tumors  resembling  in  structure 
immature  connective  tissue.  They  include  the  fibro -nucleated, 
fibro-plastic,  myeloi'd,  and  recurrent  fibroid  tumors,  and  many  of 
the  so-called  cancers  of  the  older  pathologists.  Normal  embry- 
onic tissue  in  the  course  of  development  may  become  fibrous  tissue, 
cartilage,  bone,  etc.  The  sarcomata,  however,  retain  the  struc- 
ture of  young  connective  tissue  throughout  their  life  history  ;  and 
although  in  places,  and  indeed,  in  some  instances,  in  the  greater 
part  of  the  tumor,  development  may  proceed,  as  in  the  normal 
growth  of  the  body,  to  the  formation  of  fibrous  tissue,  cartilage, 
or  bone,  yet  the  circumferential  or  growing  parts  of  the  tumor 
will  always  be  found  to  consist  of  sarcoma  elements.  Hence  the 
importance  of  examining  a  growing  part  lest  a  sarcoma  which  has 
undergone  chondrification,  ossification,  etc.,  be  pronounced  a 
cartilaginous  or  osseous  tumor.  The  sarcomata  present  the  most 
diverse  characters,  both  as  regards  their  structure  and  their 
chnical  behavior,  but  have  the  following  in  common  : — i.  The 
cells  of  which  they  are  composed  consist  of  masses  of  protoplasm 
without  distinct  cell- wall,  and  contain  one  or  more  nuclei.  2. 
Each  cell  is  surrounded  by  a  varying  amount  of  intercellular  sub- 
stance which  has  no  definite  arrangement,  and  does  not  form 
alveolar  spaces  as  in  carcinoma.  3.  The  blood-vessels  have  very 
thin  walls,  and  ramify  among  the  cells,  not  in  the  stroma  as  in 
carcinoma;  indeed,  they  are  often  mere  spaces  bounded  by  the 
cells  themselves ;  hence  the  frequency  with  which  hemorrhages 
occur  in  the  substance  of  the  growth.  4.  Dissemination  usually 
takes  place  by  the  blood-vessels  (not  by  the  lymphatics,  as  in 
carcinoma),  a  fact  which  may  probably  be  explained  by  the  above- 
mentioned  relation  of  the  vessels  to  the  cells.  5.  The  secondary 
growths,  when  dissemination  occurs,  are,  as  a  rule,  like  the  pri- 
mary, and  are  most  frequent  in  the  lungs.  6.  Sarcomata  grow 
by  invading  the  surrounding  tissue,  and  generally  return  locally 
after  removal,  probably  because  some  portion  of  infiltrated  tissue 
has  been  left.     7.  They  do  not,  as  a  rule,  affect  the  lymphatic 


TUMORS — SARCOMATA .  8  7 

glands,  except  when  they  occur  as  primary  tumors  in  such  glands, 
or  invade  glands  from  surrounding  parts,  or  when  they  grow,  as 
pointed  out  by  Mr.  Butlin,  in  the  testis  and  tonsil,  when  implica- 
tion of  the  glands  is  the  rule  rather  than  the  exception.  8.  They 
are  of  most  frequent  occurrence  in  youth  and  early  middle  life. 
9.  Their  cut  section,  when  fresh,  does  not  yield  a  milky  juice  like 
that  obtained  on  scraping  a  carcinoma. 

In  their  simplest  form  sarcomata  consist  of  small  round  cells 
resembling,  but  very  distinct  from,  leucocytes,  embedded  in  a 
scanty  amount  of  homogeneous  intercellular  substance  traversed 
by  delicate  loops  of  capillary  vessels  ;  in  fact,  they  so  closely  re- 
semble the  granulation-tissue  of  inflammation  as  to  be  micro- 
scopically indistinguishable  from  it.  In  the  higher  forms  the 
cells  become  elongated  and  of  a  spindle  shape,  and  the  inter- 
cellular substance  may  show  an  attempt  at  fibrillation  ;  or  fibrifi- 
cation,  chondrification  or  ossification  may  ensue,  and  indeed  in 
some  instances  may  proceed  to  such  an  extent  that  the  whole 
tumor  appears  composed  of  fibrous  tissue,  cartilage,  or  bone,  and 
it  may  only  be  at  the  growing  edge  that  the  sarcomatous  elements 
are  discoverable.  Notwithstanding  such  changes,  the  tumor  will 
continue  to  display  its  malignancy  in  that  it  still  invades  the  sur- 
rounding tissues,  or  becomes  disseminated  through  internal 
organs.  Sarcomata  that  have  thus  undergone  ossification,  are 
often  spoken  of  as  ossifying  sarcomata.  Ossification,  however,  is 
seldom  met  with  except  in  sarcomata  in  connection  with  bone, 
and  although  it  may  then  occur  in  all  varieties,  is  most  common 
in  the  spindle-celled  and  mixed  forms.  The  new  bone-spicula 
usually  grow  into  the  tumor  at  right  angles  to  the  shaft  of  the 
bone,  and  are  surrounded  by  sarcoma  tissue ;  whereas  in  the  true 
osteomata  the  bone-spicula  are  parallel  to  the  shaft,  and  are  sur- 
rounded by  cartilage  or  periosteum. 

Sarcomata  may  be   divided    into    four  chief  groups    (a:)   the 
round-cei/ed,    {b)     the    spindle-celled,    (^)     the 
giant-celled  ox  myeloid,  and  {d^  the  mixed-celled.  ^'°-  ^s- 

(a)    The     ROUND-CELLED     SARCOMATA     USUally  aSM^®^ 

occur  as  soft,  vascular,  and  very  rapidly  grow-     '^^  J '^"^  fSxs). 
ing  tumors,  and  often  attain  a  large  size,  and     /^^    r^  -     "' 1^^--, 
quickly  become  disseminated    through  distant    e"     '  ^  '      - ' 
parts  of  the  body  and  through  internal  organs.      '^\%  '■..^'r''"^^\e) 

Structure. — They  consist  of  round  cells  like  ^^^ti  B'©' 

leucocytes,  varying  in  size  in  different  tumors,    Round-ceiied  Sarcoma. 
and  embedded  in  a  small  amount  of  granular 
or  homogeneous  intercellular  substance.     On  section  they  appear 
soft   and  vascular,    resembling  brain  matter.     Hence   the    term 
encephaloid  ox  ?nedullary  vfhich.  is  sometimes  applied  to  them.     It 


88  GENERAL   PATHOLOGY    OF   SURGICAL    DISEASES. 

was  this  variety  of  sarcoma  that  was  formerly  called  encephaloid 
cancer.  The  microscopical  appearance  of  a  typical  specimen  is 
shown  in  Fig.  15, 

Secofidary  changes. — They  may  undergo  mucoid  softening, 
fatty  degeneration  or  ulceration,  or  blood  may  be  extravasated  in 
their  substance  leading  to  the  formation  of  cysts  {sarcojiiatous 
blood- cysts'). 

Usual  seats. — Wherever  fibrous  tissue  exists;  but  they  are  most 
common  in  the  periosteum,  bone,  skin,  subcutaneous  tissue  and 
testicle. 

Varieties  of  round-celled  sarcoma. —  i .  The  glio-sarcoma,  which 
grows  in  the  connective  tissue  of  nerves,  and  has  a  matrix  like 
that  of  the  neuroglia  of  nerve-centres.  It  occurs  most  frequently 
in  the  retina  and  brain.  2.  The  lymphosarcoma,  which  grows  in 
the  lymphatic  glands.  It  consists  of  a  reticulum  resembling 
lymphoid  tissue,  and  of  small  round  cells  usually  of  the  size  of 
leucocytes.  3.  The  psammoma,  a  very  rare  form  which  occurs 
in  the  pineal  body  and  orbit,  and  has  been  met  with  in  the  men- 
inges and  ovary,  is  by  some  pathologists  classed  with  the 
papillomata.  4.  The  alveolar  sarcoma,  in  which  the  matrix 
forms  a  net-work  enclosing  each  cell  in  a  separate  space  or 
alveolus.  5.  The  melanotic  sarcoma,  which  contains  pigment 
both  in  the  cells  and  intercellular  substance.  Its  favorite  seat  is 
in  the  skin  and  the  choroid  coat  of  the  eye — /.  e.,  in  the  situa- 
tions where  pigment  normally  exists.  It  becomes  rapidly  dissem- 
inated through  the  body,  the  secondary  growths  being  generally 
also  pigmented.  It  is  the  most  malignant  of  the  sarcomata,  and 
was  formerly  known  as  melanotic  cancer.  The  cells  are  some- 
times spindle-shaped  instead  of  round.  It  differs  from  the  pig- 
mented wart,  in  that  the  latter  is  firm,  often  pedunculated  or 
lobulated,  and  of  slow  growth. 

'J"he  signs  of  round-celled  sarcomata  vary  so  much  according  to 
the  tissue  implicated,  that  only  the  briefest  outUne  of  their  general 
course  can  be  here  given.  They  will  more  especially  be  referred 
to  under  bone,  testicle,  and  breast.  Here  it  may  suffice  to  say 
that  they  exhibit  all  the  signs  of  malignancy.  Thus  they  grow 
rapidly,  invade  the  surrounding  tissues,  the  veins  over  them  be- 
come enlarged,  and  the  skin  as  they  approach  it  becomes  inflamed 
and  finally  gives  way,  and  an  ulcerating  chasm  is  left  or  a  fungus 
protrudes.  The  health  and  strength  fail,  cachexia  sets  in,  evi- 
dence of  dissemination  of  the  disease  in  other  tissues  or  in  internal 
organs  may  be  manifested,  and  death  soon  ensues. 

Diagnosis. — It  is  often  very  difficult  to  diagnose  a  sarcoma, 
especially  of  bone,  from  the  inflammatory  affections.  The  history 
of  the  case,  the  unequal  consistency  of  the  tumor,  which  may  be 


TUMORS SARCOMATA.  89 

hard  in  places,  soft  in  others,  the  irregularity  of  its  shape,  the 
absence  of  pus  on  puncture  with  a  grooved  needle,  and  the  pro- 
gressive loss  of  weight  and  strength,  point  to  its  sarcomatous 
nature  ;  but  an  incision  into  it  will  sometimes  be  necessary  to 
clear  up  the  doubt.  The  rapid  growth  and  dark  color  of  a 
melanotic  sarcoma  are  distinctive. 

IVeaiment. — The  only  effectual  treatment  is  removal.  When 
the  tumor  is  situated  in  one  of  the  extremities  amputation  well 
above  the  disease  should  be  practised  ;  when  on  the  trunk  it 
should,  where  practicable,  be  dissected  out,  cutting  as  wide  of  the 
disease  as  possible. 

{^b)  The  Spindle- celled  (Fig.  i6)  are  the  most  common  of 
the   sarcomata,  and    are    composed   of 
spindle-shaped  cells,  varying  in  size,  and         ,^^,^^__    ^"=-  ^^• 
containing  one    or   more  nuclei.     The 
cells,   in  some  instances,   are  arranged 
concentrically  around  the  blood-vessels, 
or   in    bands ;    or   again,   in    other    in- 
stances, appear  to  have  no  definite  ar-       -^  \     v^ 
rangement.     Spindle-celled    sarcomata  Spindie-ceiied  Sarcoma. 

are  subdivided  according  to  the  size  of 

their  cells  into  the  small-spindle-celled  and  large-spindle-celled 
varieties. 

The  small- spindle-celled  sarcomata  are  firmer  and  less  rapid  in 
their  growth  than  the  round-celled  or  large-spindle-celled  forms  ; 
they  do  not  become  so  quickly  disseminated  in  internal  organs, 
and  are  therefore  less  malignant.  They  generally  recur  locally 
when  removed  ;  but  after  many  recurrences,  their  tendency  to  re- 
turn may  at  length  cease,  or  they  may,  on  the  other  hand,  assume 
a  more  malignant  form  and  become  disseminated. 

Sttiiciitre. — They  consist  of  small  spindle  cells  containing  usually 
a  single  nucleus ;  the  cells  are  embedded  in  a  small  amount  of 
homogeneous  intercellular  substance,  which  at  times  is  somewhat 
fibrillated.  They  may  at  first  be  enclosed  by  a  capsule,  but  later 
infiltrate  the  surrounding  parts.  They  appear  as  smooth  firmish 
growths,  pinkish-white,  semi-translucent,  and  fibrillated  on  section. 
Their  microscopical  appearance  is  seen  in  Fig.  16.  Secondary 
changes. — Fibrification,  chondrification,  calcification,  ossification, 
and,  when  implicating  the  skin,  ulceration.  Usual  scats. — Peri- 
osteum, fascife,  and  subcutaneous  tissue. 

The  la7'ge-spindle-celled  sarcomata  are  much  softer  than  the 
preceding  variety,  and  often  grow  rapidly,  and  quickly  become 
disseminated  ;  indeed,  they  may  be  as  malignant  as  the  round- 
celled  growths.  Structure. — They  consist  of  large  spindle  cells, 
which  frequently  contain  several  oval  nuclei,  embedded  in  a 
4* 


90 


GENERAL   PATHOLOGY    OF   SURGICAL   DISEASES. 


scanty  amount  of  intercellular  substance.  They  occur  as  non- 
encapsuled  tumors  of  soft  consistency,  frequently  in  parts  diffluent, 
and  on  section  appear  of  a  pinkish-white  color,  and  often  blotched 
with  blood.  Secojuiary  changes. — Fatty  degeneration,  blood- 
extravasation  with  the  formation  of  blood- cysts,  and  ulceration. 
Usual  seats. — The  intermuscular  fasci?e,  periosteum,  and  breast. 
Signs  and  diagnosis. — The  small-spindle-celled  sarcomata,  when 
occurring  in  the  fascige  and  subcutaneous  tissue,  appear  as  moder- 
ately firm,  or  at  times  as  softer  growths,  unattended  with  signs  of 
inflanimation  unless  involving  the  skin.  They  recur  in  situ  after 
removal,  but  do  not,  as  a  rule,  become  disseminated:  The  large- 
spindle-celled  forms  resemble  the  round-celled,  from  which  they 
cannot  be  distinguished  before  removal.  Both  varieties  are  more 
especially  referred  to  under  Diseases  of  Bone. 

Treatment. — The  small-spindle  celled  variety  should,  where 
practicable,  be  freely  and  widely  removed.  The  treatment  of  the 
large-spindle-celled  is  like  that  of  the  round-celled. 

{c)  The  Gi-vnt- celled  or  Myeloid  sarcomata  nearly  always 
occur  in  connection  with  bone,  and  will  be  more  fully  described 
in  the  section  on  Diseases  of  Bone.  They  are  usually  of  slow 
growth,  and  are  amongst  the  least  malignant  of  the  sarcomata, 
especially  when  occurring  in  the  interior  of  bone.  After  removal, 
however,  they  have  been  followed  by  the  more  malignant  forms. 
Structure. — They  consist  of  spindle  or  round  cells,  amongst 
which  are  found  large  irregularly-shaped  masses  of  protoplasm, 
containing  often  as  many  as  thirty  or  forty  oval,  highly-refracting, 
distinct  nuclei.  These  masses  of  nucleated  protoplasm  are  known 
as  giant  or  myeloid  cells,  and  resemble  those  found  in  the  marrow 
of  the  foetus.  The  microscopic  appearance  is  seen  in  Fig.  17. 
Myeloid  sarcomata  vary  from  a  firm  or 
fleshy  to  a  soft  or  jelly-like  consistency, 
and  are  neither  elastic  nor  tough.  On 
section  they  appear  uniformly  smooth, 
succulent,  shining,  semi-translucent,  but 
not  fibrillated,  of  a  livid  crimson  or 
maroon  color  not  unlike  the  muscular  tis- 
sue of  the  mammalian  heart,  and  often 
blotched  with  brighter  patches  of  pink 
or  darker  red  due  to  blood -extravasation. 
Secondary  changes.  —  Chondrification 
sometimes  occurs,  but  ossification  is  rare.  Blood-cysts  are  very 
common,  from  the  giving  way  of  some  of  the  numerous  thin- 
walled  vessels. 

Usual  seats. — In  the  interior  of  the  ends  of  the  long  bones, 
es])ecially  the  lower  end  of  the  femur  and  u]:)per  end  of  the  tibia, 
and  in  the  lower  jaw ;  less  rarely  they  grow  from  the  periosteum, 


Fig 


Myeloid  Sarcoma. 


TUMORS ADENOIMATA. 


91 


Signs,  diagnosis  and  treatment. — See  Sarcoma  of  Bone. 

(^)  The  Mixed-celled. — Many  sarcomatous  tumors  consist 
of  both  spindle  and  round  cells.  They  may  resemble  either  the 
spindle-celled  or  the  round-celled  tumors,  and  cannot  be  dis- 
tinguished without  a  microscopical  examination. 

Sarconiatoics  blood-cysts. — Soft  sarcomatous  tumors  sometimes 
become  completely  broken  down  by  extravasation  of  blood  into 
their  substance,  and  converted  into  cysts  containing  partly  fluid 
and  partly  coagulated  blood.  When  such  a  cyst  is  punctured, 
the  haemorrhage  is  often  difficult  to  control.  When  cut  into,  the 
walls  are  generally  found  ill-defined,  and  it  may  be  impossible  to 
distinguish  the  cyst  from  a  hsematoma  or  ordinary  blood-cyst, 
without  a  microscopical  examination  of  a  piece  of  the  wall. 

n.    EPITHELIAL   AND    GLANDULAR   TUMORS,    OR   TUMORS   OF   THE    TYPE 
OF    EPITHELIAL  TISSUES. 

These  may  be  divided  into  the  innocent  and  the  malignant, 
(a)    The  innocetit. 

Adenomata  or  glandular  tumors  are  innocent  growths  re- 
sembling secreting  glands  in  structure,  and  only  grow  in  con- 
nection with  pre-existing  glandular  tissue.  They  are  divided  into 
the  acinous  and  tubidar,  according 
as  they  resemble  one  or  other  of 
these  glands.  The  acinous  variety 
consists  of  acini,  lined  with  spher- 
oidal epithelium,  and  communi- 
cating with  each  other  by  duct-like 
channels.  The  acini  are  clustered 
in  twos,  threes,  or  more,  and  are 
separated  and  bound  together  by 
connective  tissue,  in  which  the  ves- 
sels ramify.  Pure  adenomata  are 
rare,  the  scanty  amount  of  inter- 
tubular  and  interacinous  connec- 
tive tissue  in  such  being  more  often 
replaced  by  fibrous  tissue  i^adeno- 

fibrovia),  or  by  mucous  tissue  {adeno-myxoma) ,  or  by  sarcomatous 
elements  {adeno-sarcomata) ,  or  by  a  combination  of  two  or  more 
of  the  above  tissues  {adetio-fibro-sarcojna,  adeno-myxo-sarcoma)  ; 
whilst  at  times  the  acini  or  ducts  become  dilated  into  cysts,  in 
which  proliferating  growths  {inti-acystic  growths^  may  project. 
The  tumor  is  then  spoken  of  as  an  adeno-cystoma,  cysto-sarcoma, 
etc.,  according  to  the  character  of  the  intertubular  and  interacinous 
connective  tissue.  The  microscopical  appearance  of  an  adenoma 
is  shown  in  Fig.  18. 


Fig.  18. 


Adenomatous  Tumor. 


92  GENERAL   PATHOLOGY    OF   SURGICAL   DISEASES. 

The  tubular  adenomata  resemble  the  tubular  glands,  the  epithe- 
lium of  this  variety  differing  from  that  of  the  acinous  in  being 
more  or  less  columnar.  They  are  most  common  in  the  mucous 
membrane  of  the  intestine,  where  they  form  papillary  or  polypoid 
growths. 

Both  varieties  are  distinguished  from  carcinoma,  in  that  the 
epithelium  does  not  penetrate  the  basement  membrane  and  invade 
the  connective  tissue. 

Usual  seats. — The  acinous  occur  in  the  mamma  (where  they 
are  generally  of  the  adeno-fibromatous  form),  the  lip,  the  prostate, 
the  thyroid,  parotid,  and  lachrymal  glands,  and  the  sebaceous 
glands  of  the  skin.  The  tubular  occur  in  the  intestine,  especially 
the  rectum. 

Secondary  changes. — Cystic  degeneration  consequent  upon 
mucoid  softening,  and  fatty  degeneration  of  the  epithelum. 

Signs,  diagnosis,  and  treatment.  See  Diseases  of  the  Breast, 
Rectum,  etc. 

(b)    The  malignant. 

Carcinomata,  or  Cancers,  are  malignant  growths  consisting  of 
epithelial-like  cells  contained  in  an  alveolar  stroma.  The  indi- 
vidual cells  are  not  surrounded  by  any  intercellular  substance  as 
in  the  sarcomata,  and  the  vessels  run  in  the  stroma,  and  not 
among  the  cells.  They  are  derived  from  pre-existing  epithelium. 
The  epithelium  is  believed  to  proliferate  and  break  through  the 
wall  of  an  acinus  or  duct,  or  the  basement  membrane  of  the  skin 
or  mucous  membrane,  and  invade  the  surrounding  or  underlying 
connective  tissue,  where  it  is  supposed  to  enter  the  lymphatic 
spaces,  and  thence,  sooner  or  later,  pass  into  the  lymphatic  vessels, 
and  so  finally  become  disseminated.  The  cells  in  carcinoma, 
though  varying  in  their  character,  retain  within  certain  limits  the 
type  of  the  epithelium  from  which  they  spring.  Thus,  they  are 
more  or  less  squamous  when  derived  from  the  skin,  squamous  or 
columnar  when  derived  from  a  mucous  membrane,  according  to 
the  character  of  the  epithelium  normally  covering  it,  spheroidal 
when  derived  from  a  gland.  The  cells  have  recently  been  very 
minutely  investigated  by  means  of  new  methods  of  staining,  and 
peculiar  bodies,  believed  by  some  pathologists  to  be  of  the  nature 
of  parasites  or  protozoa,  have  been  noted.  These  bodies,  how- 
ever, by  other  observers,  are  held  to  be  nothing  more  than  phases 
of  cell-degeneration  de])ending  upon  chronic  irritation  or  other 
causes.  The  alveoli  in  which  the  cells  are  contained  are  by  many 
regarded  as  the  lymjjhatic  spaces  natural  to  the  affected  tissue, 
dilated  by  the  invading  epithelium,  but  this  view  is  probably  in- 
correct.    The  stroma  surrounding  the  alveolar  spaces  at  first  con- 


TUMORS CARCINOMATA.  93 

sists  of  the  connective  or  other  tissue  of  the  invaded  parts,  infil- 
trated more  or  less  with  small  round  cells.  This  small-cell- 
infiltration  is  ascribed  to  the  irritation  of  the  epithelial  invasion, 
and  from  it  is  believed  to  be  later  derived  the  fibrous  tissue  con- 
stituting the  dense  stroma  of  some  forms  of  carcinoma. 

The  blood-vessels  which  run  in  the  stroma  are  numerous  in  the 
more  rapidly  growing  tumors,  and  especially  in  the  circumferen- 
tial parts,  but  are  much  fewer  in  number  in  the  more  chronic 
forms,  and  in  the  central  parts  of  the  latter  may  be  obUterated  by 
the  growth  of  the  fibrous  tissue.  Hence  the  frequency  with  which 
fatty  degeneration  of  the  cells,  and  breaking  down  {ulceration)  of 
older  parts  of  the  tumor  occur.  In  the  softer  or  rapidly  growing 
forms,  in  which  the  stroma  is  scanty  and  the  support  that  the  ves- 
sels receive  from  it  consequently  but  slight,  haemorrhages  are  fre- 
quent. Carcinomata  have  no  capsule,  grow  by  cell-division,  and 
continued  invasion  of  the  surrounding  tissues,  and  sooner  or  later 
break  down  and  ulcerate.  They  implicate  the  nearest  lymphatic 
glands,  and  finally  become  disseminated.  At  first  the  general 
health  is  usually  but  little  affected  ;  but  later,  partly  owing  to  the 
local  ulceration,  and  partly  owing  to  the  dissemination  of  the 
growth,  a  condition  known  as  cancerous  cachexia  sets  in,  the  skin 
becoming  sallow  and  of  a  peculiar  earthy  color,  the  face  careworn 
and  anxious,  and  the  body  emaciated.  The  strength  fails,  and 
the  patient  at  length  dies  of  exhaustion,  induced  by  the  general 
interference  with  nutrition,  local  ulceration,  haemorrhages,  pain 
and  mental  anxiety. 

Varieties  of  Carcinoma. — The  carcinomata  are  divided  into 
three  great  classes  :  (i)  The  spheroidal-celled ;  (2)  the  squamous- 
celled  (epitheliomata)  ;  and  (3)  the  columnar-celled,  or  the  ade 
noid or  glandular  carcinotnata.  The  spheroidal-celled  are  further 
divided  into  (a)  the  hard  spheroidal-celled,  (^)  the  soft  spheroidal- 
celled,  and  (r)  the  colloid v^ueiy,  which  is  probably  a  degenerated 
condition  of  one  or  other  of  the  former,  or  indeed  of  any  variety 
of  carcinoma,  except  the  squamous-celled  (epithelioma). 

I.  The  spheroidal- celled  or  acinous  carcinomata  consist  of 
epithelial  cells  resembhng  spheroidal  or  glandular  epithelium,  and 
only  grow  in  connection  with  glands.  They  usually  exhibit  the 
characteristic  alveolar  structure  of  the  carcinomata  in  a  well- 
marked  degree.  They  are  divided  into  the  hard  spheroidal- 
celled,  the  soft  spheroidal-celled,  and  the  colloid  varieties. 

{a)  The  hard  sphe7-oidal-cellcd  carcinomata,  the  scirrhous  or 
chronic  cancers  are  moderate-sized,  hard,  nodular,  and  compara- 
tively slowly-growing  tumors,  v/hich,  sooner  or  later,  ulcerate,  and 
become  disseminated  through  the  body. 

Structure. — They  are  characterized  by   the   large   amount    of 


94  GENERAL   PATHOLOGY   OF    SURGICAL   DISEASES. 

their  stroma  (Fig.  19).  Indeed,  the  central  parts  of  the  growth, 
in  some  cases,  consist  of  little  else  than  dense  fibrous  tissue,  with 
a  few  atrophied  and  fatty-looking  cells  in  the  shrunken  alveoli. 

The    circumferential    parts   of    such 

Fig.  19-  tumors,  however,  still  display  the  typi- 

^^_^^  ,  ^  cal  characters  of  acinous  carcinoma, 

'^7-^,  .-^  ^v-'/        and    in  the   surrounding   tissues   the 

'^slC'  ■        '        ^      epithelial  invasion  and  the  small-cell- 

^.:__:  ^         infiltration  are   still  going    on.     It  is 

/^;         7  ,'     owing   to  the  excessive  formation  of 

^    ,'jC-  :        /' ;  ■'  '      fibrous  tissue  that  the  scirrhous  cancer 

^•j^-  _  is   so    hard,   and    creaks   under   the 

"^J/^:-  ',  .    '_     knife  when  cut ;  and  to  the  tendency 

^  r    '  of  the  fibrous  tissue  to  shrink,  that  the 

^,-'  "7^<,  skin  over  the  tumor  becomes  puck- 

"  .       ^  ered,  and  the  nipple  in  the  case  of  the 

Hard  spheroidal-celled  or  scirrhous  ,         .     j      „  j  i.u^4.  ^.u  „„,,*.  „ 

Carcinoma.  mamma  retracted,  and  that  the  cut  sur- 

face of  the  tumors  becomes  concave. 

Usual  seals. — The  breast ;  but  scirrhous  cancer  also  occurs  in 
the  pylorus,  and,  more  rarely,  in  other  situations.  The  general 
appearance  of  scirrhous  cancer,  the  symptoms,  diagnosis,  varieties 
and  treatment,  are  given  under  Diseases  of  the  Breast,  its  favorite 
seat. 

{b)  The  soft  spheroidal-celled  carcinomata,  the  medullary,  ence- 
phaloid  or  acute  ca7icers,  are  much  more  rapid  in  their  growth 
than  the  preceding  variety,  and  form  soft  and  often  large  tumors, 
quickly  terminating  in  ulceration  and  general  dissemination 
through  the  body.  Structm-e. — The  stroma  is  scanty  in  amount 
(Fig.  20),  and  does  not  contract  like 
that  of  scirrhous  ;  the  cells,  which  are  ^ig.  zo. 

very  prone  to  undergo  fatty  degen- 
eration, are  contained  in  brge  alveoli. 
These  cancers  are  very  vascular,  and 
as  the  scanty  stroma  affords  but  little 
support  to  the  vessels,  extensive  haem- 
orrhages into  the  substance  of  the 
growth  are  common.  On  section, 
they  appear  of  a  grayish-white  or  ;'•'([  '<^'i)J^£Ji^^_ 
cream-color,  blotched  in  places  with  )jp^*^"\C^y  " 

blood,  whilst  in  the  centre  they  may  '       .  ^'"- 

,1  ^     1  ■  rn  i  ^  Soft    spheroidal-celled    or    medullary 

be  almost  diffluent,  consequent  upon  carcinoma, 

their  having  undergone  fatty  degen- 
eration.    On  account    of  the  resemblance  to   brain  matter,  the 
older  pathologists  termed  them  cucephaloid  cancers.     After  they 
have   involved  the  skin,  they  protrude  in  the  form  of  a  bleeding 


TUMORS — CARCINOMATA.  95 

fungating  mass,  and  hence  were  further  called  fungus  hcBtnatodes. 
Although  in  accordance  with  general  usage,  the  spheroidal-celled 
carcinoraata  are  divided  into  hard  and  soft,  it  should  be  under- 
stood that  no  hard-and-fast  hne  can  be  drawn  between  them,  as 
the  characters  of  the  one  often  merge  into  those  of  the  other,  so 
that  sometimes  it  may  be  difficult  to  decide  whether  an  individual 
spheroidal-celled  carcinoma  should  be  classed  as  hard  or  soft. 

Usual  seats. — The  testis,  liver,  bladder,  kidney,  ovary  and 
breast.  Secondary  growths  in  internal  organs  consequent  upon 
the  dissemination  of  scirrhous  cancer  are  often  of  the  soft  variety. 

(yC)  Colloid,  gelatiniform,  or  alveolar  carcinomata. — These 
terms  are  applied  to  either  of  the  above-described  varieties,  or 
indeed  to  any  form  of  carcinoma  which  has  undergone  mucoid 
or  colloid  degeneration.  It  is  believed  that  the  degeneration 
generally  begins  in  the  cells  which,  as  they  become  enlarged,  so 
distend  the  alveoli  that  the  latter  can  be  seen  by  the  naked  eye. 
The  colloid  material  is  glistening,  semi-translucent  and  jelly-like, 
or  in  places  diffluent.  In  it  some  spheroidal  cells  are  generally 
found.  The  faiw rite  seats  of  these  cancers  are  the  stomach,  intes- 
tine, omentum  and  ovary ;  but  they  occasionally  occur  in  the 
breast. 

2.  The  squamous-celled  carcinomata  {Epitheliomata)  always 
spring  from  the  skin  or  a  mucous  membrane,  covered  by  squamous 
epithelium,  and  constitute  the  second  great  division  of  the  cancers. 
They  are  characterized  by  the  resemblance  of  their  cells  to  squamous 
epithelium.  The  typical  alveolar  arrangement  of  the  carcinomata 
is  much  less  well  marked  than  in  the  spheroidal-celled  or  acinous 
variety. 

It  was  to  this  squamous-celled  form  of  carcinoma  that  the  term 
"epithelioma"  was  originally  applied;  but  as  all  carcinomas  are 
now  believed  to  be  epithelial  growths,  the  term  "squamous-celled" 
is  prefixed  to  this  variety  to  distinguish  it  from  the  columnar- 
celled  and  the  spheroidal-celled  carcinomata.  Squamous-celled 
carcinomata  may  spring  either  from  the  skin  or  from  any  mucous 
membrane  covered  with  squamous  epithelium,  and  are  especially 
common  where  skin  and  mucous  membrane  meet,  as  in  the  lip, 
anus,  &:c.  They  are  most  frequent  in  the  old,  seldom  occurring 
under  forty  years  of  age,  and  are  more  common  in  men  than  in 
women.  They  are  usually  the  result  of  continued  irritation  ;  thus 
in  the  tongue  they  may  be  due  to  the  presence  of  a  jagged  tooth, 
in  the  lip  to  the  constant  contact  of  a  hot  pipe-stem,  in  the 
scrotum  to  the  retention  of  soot  or  coal-tar  in  the  folds  of  the  skin. 
They  are  also  not  uncommon  in  situations  where  the  epithelium 
is  in  an  abnormal  condition,  as  in  old  scars,  white  patches  on  the 
tongue  and  inside  of  the  cheek,  chronic  ulcers,  warts,  and  moles. 


96 


GENERAL    PATHOLOGY    OF    SURGICAL    DISEASES. 


Structure. — A  squamous-celled  carcinoma  consists  of  solid 
columns  of  epithelium,  which  have  perforated  the  basement  mem- 
brane, and  have  grown  into  the  connective  or  other  underlying 
tissue.  The  columns  are  surrounded  by  an  imperfectly  fibrillated 
stroma,  and  a  small-cell-infiltration.  They  branch  out  laterally, 
and  by  uniting  with  similar  lateral  branches  of  other  columns  form 
an  irregular  epithelial  network.  At  the  same  time  the  epithelium 
is  usually  also  proliferated  outwards,  forming  a  warty  excrescence 
or  cauliflower-like  growth.  Breaking  down  rapidly  ensues,  and  an 
epitheliomatous  ulcer  is  the  result.  Amongst  and  around  the 
columns  of  invading  epithelium  are  found  in  places  small  collec- 
tions of  cells  of  a  crescentic  shape,  arranged  concentrically  around 
one  or  more  central  rounded  cells.  These  collections,  spoken  of 
as  cell-nests,  are  probably  due  to  the  more  rapid  growth  of  the 
epithelium  at  certain  spots,  the  shape  and  arrangement  of  the 
peripheral  layers  of  the  cells  being  due  to  their  compression  be- 
tween the  rapidly-growing  central  cells  and  the  surrounding  tissues. 

In  the  accompanying  wood- cut    (Fig.  21)  the  down-growing 


Fig.  21. 


llT      ^Hlt 


Squamous-celled  Carcinoma  (I'.pithclionia). 
(From  Piowlby's  I'athology). 


epithelial  columns,  a  column  in  transverse  section,  and  several 
cell-nests,  are  seen. 

Usual  scats. — Tongue,  lower  lip,  cheeks,  gums,  vulva,  scrotum, 
penis  and  anus. 

Signs. — A  squamous-celled  carcinoma  usually  begins  as  a  warty 
tubercle,  which  soon  becomes  an  ulcer  with  raised,  everted,  sinu- 


TUMORS — CARCINOMATA .  9  7 

ous  and  indurated  edges,  and  a  hard,  warty,  and  irregular  base, 
whilst  the  tissues  around  become  infiltrated  with  the  growth  and 
the  nearest  lymphatic  glands  enlarged.  At  other  times  it  begins 
in  a  crack  or  fissure,  and  the  ulceration  keeping  pace  with  the 
epithelial  invasion,  the  margins  of  the  ulcer  are  sharply  defined, 
and  may  be  undermined  ;  or  again  the  growth  may  have  the  ap- 
pearance of  a  cauliflower-like  mass  of  warts,  often  of  horny  con- 
sistency, projecting  above  the  level  of  the  surrounding  skin.  Un- 
less an  epithelioma  is  removed  whilst  the  disease  is  still  local, 
recurrence  usually  takes  place  in  the  nearest  lymphatic  glands  ;  at 
times,  like  other  forms  of  cancer,  though  less  often,  it  may  be- 
come disseminated  through  internal  organs.  When  incompletely 
removed  it  will  return  in  the  scar.  Death  is  usually  the  result  of 
exhaustion  consequent  upon  ulceration  and  hemorrhage.  The 
sig?is,  diagnosis,  and  t)-eatinent  are  further  referred  to  under 
Diseases  of  Regions.     (See  Lip,  Tongue,  etc.') 

3.  Columnar-celled  carcinomata,  cylindrical  carcinomata 
or  adenoid  cancers  consist  of  cells  derived  from  columnar  or 
cylindrical  epitheUum,  and  are  less  common  and  usually  of  slower 
growth  than  the  former  varieties.  They  often  begin  as  papillary 
outgrowths  from  the  surface  of  mucous  membranes  covered  with 
columnar  epithelium,  or  from  the  interior  of  the  mucous  glands, 
and  are  most  common  in  the  rectum,  though  they  may  affect 
other  parts  of  the  intestine,  the  uterus,  etc. 

Structure. — They  consist  of  tubes  lined  with  columnar  epithe- 
lium, and  bound  together  by  a  delicate  connective-tissue  stroma 
more  or  less  infiltrated  with  small  round  cells.  The  epithehal 
cells  retain  more  or  less  their  shape,  and  are  arranged  at  right 
angles  to  the  walls  of  the  alveoli,  generally  leaving  a  central  space. 
In  the  more  rapidly  growing  tumors,  however,  the  alveoli  become 
completely  filled  with  the  cells.  Like  other  carcinomata  they 
infiltrate  the  surrounding  tissues,  and  may  affect  the  lymphatic 
glands,  and  later  become  disseminated  in  internal  organs,  espe- 
cially the  liver.  Death,  however,  usually  occurs  from  obstruction 
of  the  bowel,  haemorrhage  from  the  ulcerating  surface,  or  exhaus- 
tion, rather  than  from  dissemination.  Their  appearance,  symp- 
toms, diagnosis,  and  treatment  are  further  described  under 
Diseases  of  the  Rectum. 

The  treatment  of  carcinoma  generally  may  be  divided  into 
the  palliative  and  radical.  The  palliative  is  resorted  to  when 
from  some  cause  a  cancer  cannot  be  removed  by  operation,  and 
consists  briefly  in  soothing  pain  by  opium,  neutralizmg  the  offen- 
sive smell  when  ulceration  has  occurred  by  antiseptics,  and  sup- 
porting the  strength  by  nourishing  diet  and  stimulants.  The. 
radical  treatment  aims  at  removing  the  cancer  by  operation,  in 
5 


98  GENERAL   PATHOLOGY    OF   SURGICAL   DISEASES. 

the  hope  that  it  may  not  return  or  manifest  itself  in  other  parts. 
If  removed  early,  there  is  a  good  chance  of  the  squamous-celled 
carcinoma  not  doing  so,  and  in  some  forms  of  the  columnar  and 
spheroidal-celled  the  same  fortunate  result  has  occasionally  oc- 
curred. As  a  rule,  however,  the  issue  is  not  so  favorable,  and 
after  an  immunity,  varying  in  duration  according  to  the  variety, 
situation,  and  size  of  the  tumor,  the  length  of  time  it  has  existed, 
and  the  implication  or  non-implication  of  the  lymphatic  glands, 
the  disease  returns  in  the  scar,  in  the  lymphatic  glands,  or  in 
internal  organs.  But  though  the  patient  may  not  be  cured  by  an 
operation,  he  may  be  greatly  relieved  by  the  removal  of  the  local 
trouble,  and  die  with  less  distress  from  the  implication  of  internal 
organs.  Should  removal  be  determined  on,  it  is  best  done  by  the 
knife;  but  in  certain  parts  the  scissors  or  tcraseur  may  be  more 
applicable.  At  times  caustics  may  be  employed.  Recently  it 
has  been  urged  that  electrolysis  is  capable  of  so  acting  on  the 
cancer-cells  as  to  prevent  further  growth  and  produce  shrinking ; 
but  there  is  at  present  no  trustworthy  evidence  that  it  has  any 
such  action.  The  various  methods  of  removing  carcinomata  will 
be  described  more  in  detail  under  Diseases  of  Regions. 

CYSTS. 

A  cyst  is  a  closed  sac  containing  fluid  or  pultaceous  matter. 
Cysts  may  be  divided  into  : 

I.    Cysts  formed  by  distension  of  natiu-ally-cxisiing  cavities  or 
spaces. 

11.   Cysts  of  new  formation. 
III.   Cysts  of  congenital  origin. 

I.   Cysts  formed  by  distension    of  naturally- existing  cavities  or 

spaces. 

These  are  subdivided  into  :  A.  Exudation  cysts  ;  B.  Retention 
cysts ;  and  C.  l<>xtravasation  cysts. 

A.  Exudation  cysts  are  formed  by  exudation  or  by  excessive 
secretion  into  cavities  which  have  no  excretory  duct.  Under  this 
head  are  included  Bursse,  Ganglia,  Cystic  Bronchoceles,  and  Cysts 
in  the  ovary  due  to  the  dilatation  of  Graafian  follicles.  They  will 
be  further  referred  to  under  Diseases  of  Bursjc,  Ganglia,  etc. 

B.  Rkten'I'ion  cysts  are  formed  by  the  retention  of  the  normal 
secretion  and  the  consequent  dilatation  of  the  ducts  or  acini  of  the 
affected  gland.  They  are  lined  with  epithelium  ;  their  walls  be- 
come thickened  by  fibroid  changes  ;  and  the  natural  secretion  is 
altered  by  inspissation  or  by  exudadon  from  the  cyst-wall.  Three 
forms  are  described  :   i,  atheromatous  or  sebaceous  cysts  due  to 


RETENTION   CYSTS.  99 

the  dilatation  of  the  sebaceous  glands ;  2,  mucous  cysts  formed  by 
the  dilatation  of  mucous  glands  ;  and  3,  cysts  produced  by  the 
distension  of  special  ducts,  as  the  sahvary,  lacteal,  hepatic,  and 
renal  ducts,  and  tubules  of  the  testicle. 

1.  Atheromatous  or  sebaceous  cysts  (vaefis)  occur  mostly  on 
the  scalp  or  face,  but  may  be  met  with  on  any  part  of  the  body, 
and  are  often  multiple.  They  do  not  contain  hair  follicles, 
papillae,  or  other  skin  elements,  thereby  differing  from  the  der- 
moid cysts  which  they  otherwise  resemble.  Those  on  the  scalp 
are  sometimes  hereditary.  S(^ns. — They  form  smooth  lens- 
shaped,  semi-fluctuating,  movable  swellings,  often  adherent  to  the 
skin.  They  may  be  distinguished  from  a  fatty  tumor  by  not 
slipping  from  under  the  finger  on  pressing  the  edge  of  the  swell- 
ing, and  from  an  abscess  by  the  absence  of  signs  of  inflamma- 
tion. A  small  black  punctum,  the  obstructed  orifice  of  the  seba- 
ceous follicle,  may,  except  in  cysts  of  the  scalp,  generally  be 
discovered  on  the  surface.  Secondary  changes. — i.  The  contents 
of  the  cyst  may  undergo  decomposition  and  become  extremely 
offensive.  2.  The  cyst-wall  may  become  inflamed  and  suppu- 
rate, and  be  thus  cured ;  or  a  portion  of  the  wall  may  escape,  and 
a  sinus  ensue ;  or  the  wound  may  heal  and  the  cyst  refill.  3. 
One  part  may  give  way,  and  the  sebaceous  matter  exude,  become 
hardened,  and  be  pushed  up  from  below,  and  take  the  form  of  a 
horny  growth.  4.  Granulations  may  spring  up  from  the  interior 
of  the  cyst,  and  exude  as  a  fungating  mass  resembling  an  epithe- 
lioma. 5.  They  may  degenerate  into  an  epithehoma.  6.  Their 
walls  may  undergo  calcification.  Treatment. — They  may  be  re- 
moved by — (a)  Dissection,  (b)  Splitting  them,  squeezing  out 
the  sebaceous  matter,  and  seizing  the  cyst-wall  with  forceps  and 
pulling  it  out.  Care  should  be  taken  not  to  leave  any  of  the  wall 
behind,  or  a  troublesome  sinus  will  remain.  i^c)  Dilating  the 
orifice  with  a  probe,  and  squeezing  out  the  contents.  They  are 
apt,  however,  to  refill  when  emptied  in  this  way,  unless  the  cyst- 
wall  is  also  squeezed  out  or  sufficient  inflammation  is  set  up  to 
destroy  it. 

2.  Mucous  cysts  are  formed  by  the  dilatation  of  mucous  glands. 
They  occur  in  the  lips,  mouth,  labia,  and  other  situations  where 
mucous  glands  exist.  In  the  mouth  they  constitute  one  form  of 
ranula.  The  so-called  dropsy  of  the  antrum  is  generally  believed 
to  be  due  to  the  dilatation  of  one  of  the  mucous  glands  of  the 
lining  membrane  of  that  cavity,  and  the  cysts  met  with  at  the  en- 
trance of  the  vagina  to  a  dilatation  of  Bartholin's  glands.  The 
walls  of  mucous  cysts  are  thinner  than  those  of  the  sebaceous 
variety ;  the  contents  are  viscid  and  mucoid  in  character,  and- 
cholesterine  is  at  times    present.      Treatment. — Excision  of    a 


100  GENERAL   PATHOLOGY   OF    SURGICAL   DISEASES. 

piece  of  the  wall,  and  touching  the  interior  with  nitrate  of  silver 
or  other  caustic  will  generally  cure  them ;  if  not,  the  cyst  must 
be  dissected  out. 

3.  Cysts  formed  by  the  dilatation  of  special  ducts. — As  exam- 
ples of  these  may  be  mendoned,  dilatation  of  Wharton's  duct 
{ratiitla),  of  a  lacteal  duct  {galactocele),  and  of  a  tubule  of  the 
testicle  {encysted  hyd?-ocele).  For  a  further  account,  see  Dis- 
eases of  Regions. 

C.  Extravasation  cysts  are  formed  by  extravasation  of  blood 
into  closed  cavities,  as  the  tunica  vaginalis  of  the  testicle  {Jiaina- 
tocele),  etc. 

II.    Cysts  of  New  Formation. 

These  are  divided  into — A.  Serous  cysts ;  B.  Blood-cysts  ;  C. 
Proliferous  compound  cysts ;  and  D.  Parasitic  cysts. 

A.  Serous  or  simple  cysis  are  thin-walled  cysts,  lined  with  a 
single  layer  of  endothelium,  and  containing  a  sticky  serous  fluid. 
They  are  supposed  to  be  formed  by  the  accumulation  of  fluid  con- 
sequent upon  irritation,  pressure,  etc.,  in  the  lymphatic  spaces  of 
the  connective  tissue,  these  spaces  subsequently  becoming  fused 
into  a  single  cavity.  Their  walls  consist  of  fibrous  tissue  formed 
by  the  condensation  of  the  surrounding  connective  tissue  by  the 
pressure  of  the  fluid.  As  examples  of  serous  cysts  may  be  men- 
tioned :  adventitious  burs?e  developed  over  prominences  of  bone, 
some  forms  of  ganglion,  and  simple  cysts  in  the  breast,  neck,  etc. 
By  some  pathologists,  however,  the  serous  cysts  found  in  the  neck 
are  regarded  as  congenital  formations.  Those  in  the  median  line 
are  undoubtedly  formed  by  the  enlargement  of  pre-existing  bursae, 
e.  g.,  those  about  the  hyoid  bone. 

B.  Blood-cysts  or  h^ematomata  may  be  subdivided  into — i. 
True  blood-cysts,  which  are  most  commonly  met  with  in  the  neck, 
and  consist  of  thin-walled  cysts  containing  pure  blood.  Their 
mode  of  origin  is  doubtful,  but  they  appear  to  have  some  connec- 
tion with  the  veins,  since  if  tapped  they  often  bleed  very  freely,  2. 
Cysts,  formed  by  condensation  of  the  tissues  around  a  mass  of  ex- 
travasated  blood.  In  such  the  blood  may  become  absorbed  or 
organized  ;  or  it  may  break  down  and  disintegrate,  or  deposit  fibrin 
upon  the  wall  of  the  cyst ;  or  suppuration  may  occur  and  an  abcess 
ensue.  They  are  common  in  the  scalp  {cephalhannatoma) ,  and 
on  the  ear  \hcemat07na  airris),  but  may  occur  in  any  situation 
after  injury. 

The  extravasation  of  blood  into  serous  cavaties  and  into  solid 
tumors  is  also  by  some  included  under  Hsematoma ;  but  such  a 
classification  is  misleading  (see  Hcematocele,  Sarcotna). 

C.  Proliferous  compound  cysts  are  cysts  containing  growths. 


PARASITIC    CYSTS.  lOI 

They  are  most  common  in  the  breast  and  ovary,  and  will  be  found 
more  fully  described  under  Diseases  of  the  Breast.  These  cysts 
are  developed  in  connection  with  the  growth  of  solid  tumors,  and 
must  be  distinguished  from  cystic  degeneration,  which,  as  has 
already  been  shown,  is  very  common  in  some  forms  of  tumor.  In 
the  one  case,  the  cysts,  which  may  be  regarded  as  primary,  con- 
tain growths  sprmging  from  their  walls  or  projecting  into  them 
from  the  growths  around.  In  the  other  case,  the  cysts  are  second- 
ary, and  are  produced  by  the  degeneration  and  softening  of  the 
tumor-elements,  or  by  the  extravasation  of  blood  into  the  sub- 
stance of  the  tumor. 

D.  Parasitic  cysts  are  such  as  are  formed  in  the  tissues  around 
a  parasite.  Hydatid  cysts  only  are  here  described  ;  for  an  account 
of  other  parasitic  cysts,  the  student  is  referred  to  a  work  on 
Pathology. 

Hydatid  cysts  may  occur  in  any  of  the  tissues  or  organs  of  the 
body,  but  are  most  often  met  with  in  the  liver.  They  are  the  cystic 
stage  in  the  development  of  the  cestode  worm,  known  as  the  TcBnia 
echinococcus.  This  worm  in  the  mature  form  inhabits  the  intestine 
of  the  dog.  Thence  the  ova  may  accidentally  contaminate  food 
or  water,  and  so  gain  admission  to  the  human  intestine.  The  ova 
is  then  hatched,  and  the  embryo  may  make  its  way  by  the  portal 
vein  to  the  liver,  or  by  other  channels  to  some  other  part  of  the 
body,  where  it  becomes  converted  into  a  cyst.  The  cyst  is 
formed  of  an  external  latninated  elastic  layer  and  of  a  lining  mem- 
brane, a  parenchymatous  layer,  composed  of  cells,  granules,  and 
muscle-fibers,  and  a  water  vascular  system.  Around  the  cyst  a 
fibrous  capsule  is  formed  as  the  result  of  the  irritation  of  the  con- 
nective tissue.  The  cyst  is  filled  with  a  clear  or  slightly  opalescent 
watery  fluid  containing  a  trace  of  sugar  but  no  albumen.  As  the 
cyst  enlarges,  vesicles  or  brood  capsules  are  developed  from  the 
lining  membrane,  and  in  them  scolices,  or  small  cyst-Hke  bodies  fur- 
nished with  four  suckers  and  a  crown  of  booklets,  are  formed.  From 
the  brood-capsules  secondary  or  daughter  cysts  may  be  developed, 
having  the  same  structure  as  the  primary  or  mother  cyst,  and  in 
them  again  tertiary  or  granddaughter  cysts.  At  times  the  mother 
cyst  does  not  contain  any  vesicles  or  brood-capsules,  and  is  then 
called  sterile.  At  other  times,  as  in  the  shafts  of  bones,  there  may 
be  no  mother  cyst,  a  condition  known  as  muliilocular  hydatids. 
The  cyst  may  (i)  cease  to  grow,  die,  and  be  converted  into  a 
putty  or  mortar-like  mass  of  tissue  undergoing  in  places  calcifica- 
tion ;  (2)  it  may  suppurate,  or  (3)  burst  spontaneously.  The  signs 
of  an  hydatid  cyst  of  course  vary  according  to  the  situation  of  the 
cyst.  All  that  can  be  here  said  is  that,  when  the  cyst  is  in  an  ac- 
cessible situation,  it  gives  rise  to  a  tense,  elastic,  more  or  less 


102  GENERAL   PATHOLOGY    OF   SURGICAL   DISEASES. 

globular  fluctuating  swelling,  of  slow  growth,  in  which  on  percus- 
sion a  peculiar  thrill  may  be  felt,  the  so-called  hydatid  fremitus. 
The  treatment  should  be  preventive  and  curative.  Preventive 
treatment. — Seeing  that  the  dog  is  infected  by  eating  the  offal  of 
the  sheep  and  pig,  in  which  the  worm  resides  in  its  cestode  state, 
and  that  man  is  infected  by  food  or  water  contaminated  by  the 
dog's  excreta,  which  contain  the  ova  of  the  tinea,  the  dog  should 
be  prevented  from  having  access  to  such  food,  and  an  attempt 
should  be  made  to  destroy  the  worm  and  its  ova.  Thus,  dogs 
should  be  purged  and  given  anthelmintics,  whilst  their  kennels 
should  be  scalded,  and  the  excrement  buried  or  burnt.  All  green 
food,  as  water-cress,  that  runs  the  risk  of  being  fouled  by  dogs, 
should  be  well  cleansed  before  it  is  eaten.  Curative  Treatment. 
— The  cyst  should  be  removed  entire  where  practicable.  Where 
this  is  impossible,  it  should  be  incised,  the  contents  evacuated, 
and  the  cavity  drained,  or  better,  the  true  cyst-wall  should  be 
shelled  off  the  fibrous  capsule,  and  the  latter  left  to  granulate. 
Aspiration  or  puncture  is  highly  dangerous,  especially  in  the  case 
of  abdominal  hydatids.  Although  many  cysts  have  been  thus 
cured,  sudden  death,  secondary  infiltration  of  the  peritoneal 
cavity  with  the  hydatids,  peritonitis,  and  other  accidents  have  fol- 
lowed this  treatment.  When  the  cyst  has  suppurated,  it  should 
be  opened,  washed  out  and  drained. 

III.   Cysts  of  Congenital  Origin. 

Congenital  cysts  may  be  formed  in  various  ways  : — i.  By  the 
inclusion  of  a  portion  of  the  epiblast  within  the  mesoblast  {dermoid 
cysts).  2.  By  the  distension  in  after  life  of  some  loetal  structure 
which  has  not  become  obliterated  in  the  course  of  normal  develop- 
ment ;  for  example,  encysted  hydrocele  of  the  spermatic  cord 
developed  in  an  unobliterated  portion  of  the  funicular  process  of  the 
tunica  vaginalis,  and  certain  broad  ligament  cysts  developed  from 
the  parovarium.  (See  Testicle,  qt'c.).  3.  By  the  inclusion  of  a 
blighted  ovum  in  a  part  of  the  embryo.  Such  at  least  is  the  origin 
ascribed  to  certain  cysts  containing  pieces  of  bone,  cartilage,  teeth, 
etc.,  occasionally  found  in  connection  with  the  ovary  and  testicle. 

Another  form  of  congenital  cyst,  known  as  the  cystic  hygroma, 
is  not  uncommon.  It  consists  of  dilated  lymphatic  spaces  with 
a  varying  amount  of  fibrous,  fatty  and  naevoid  tissue  around, 
being  almost  solid  or  quite  cystic  according  to  the  proportion  of 
the  solid  elements.  Hygromata  occur  in  the  neck,  axilla,  scrotum, 
etc.     Their  origin  has  not  at  present  been  satisfactorily  explained. 

Of  the  congenital  cysts,  the  De?-moid  only  are  described  here. 

Dermoid  cysts  are  cysts  in  the  walls  of  which  are  found  all  the 
structures  constituting  the  true  skin  and  its  appendages,  such  as 


DERMOID   CYSTS.  103 

hair,  hair-follicles,  sebaceous  glands,  etc.  The  contents,  which 
resemble  sebaceous  matter,  consist  of  the  secretion  of  the  glands 
in  the  cyst-wall,  and  of  epithelial  debris,  and  frequently  of  hair. 
They  are  often  quite  unconnected  with  the  skin,  and  their  origin 
is  attributed  to  the  inclusion  of  a  portion  of  the  epiblast  in  the 
mesoblast,  an  explanation  which  in  the  region  of  the  neck  and 
face  is  probably  correct,  as  these  cysts  are  usually  formed  about 
the  outer  angle  of  the  orbit,  and  in  other  of  the  situations  at 
which  in  the  embryo  a  cleft  or  fissure  exists  between  the  processes 
from  which  the  face  or  neck  are  developed.  In  some  dermoid 
cysts  of  the  ovary  teeth  also  are  occasionally  found.  The  origin 
of  these,  as  of  the  dermoid  cysts  of  the  testicle,  are  not  so  obvious. 
Signs. — The  dermoid  cyst  so  common  near  the  outer  angle  of 
the  orbit  forms  a  smooth,  tense,  globular  tumor,  generally  freely 
movable  on  the  parts  beneath.  It  is  always  congenital,  grows 
slowly,  and  though  generally  small  may  attain  a  considerable  size. 
Treatment. — The  cyst  should  be  dissected  out  by  an  incision 
through  and  parallel  to  the  eye -brow,  in  order  that  the  scar  may 
be  as  much  as  possible  hidden.  At  times  these  cysts  send  pro- 
cesses beneath  the  eyelid,  or  into  the  orbit,  and  they  have  even 
been  known  to  perforate  the  bone  and  extend  into  the  interior  of 
the  skull.     Care,  therefore,  is  necessary  in  their  removal. 


I04  GENERAL   PATHOLOGY   OF   INJURIES. 


SECTION  II. 
GENERAL  PATHOLOGY  OF  INJURIES. 

WOUNDS. 

Wounds  are  divided  into  two  great  classes,  the  open  and  the 
subcutaneoiis. 

Open  wounds. — A  wound  has  been  defined  as  "  a  solution  of 
continuity  in  any  part  of  the  body,  suddenly  made  by  anything 
that  cuts  or  tears,  with  division  of  the  skin."  Here  our  attention 
will  be  confined  to  the  general  pathology  and  treatment  of  wounds 
of  the  soft  tissues.  Wounds  of  special  tissues,  as  bone,  muscle, 
blood-vessels,  nerves,  etc.,  will  be  further  referred  to  under  those 
heads. 

The  PROCESS  OF  repair  in  open  wounds  of  the  soft  tissues 
differs  according  as  the  wound  is  incised,  lacerated,  contused,  or 
punctured,  and  according  as  it  is,  or  is  not,  kept  aseptic,  properly 
drained,  and  protected  from  infective  processes.  The  healing 
process  will,  moreover,  be  influenced  by  the  patient's  state  of 
health  previous  to  the  wound,  and  the  hygienic  conditions  under 
which  he  is  subsequently  placed.  Let  us  first  take  a  general 
view  of  the  process  of  repair  as  it  occurs  in  a  simple  incised  wound 
in  a  healthy  subject.  Immediately  the  wound  is  inflicted  there 
will  be  free  hemorrhage  varying  in  amount  according  to  the 
vascularity  of  the  part,  probably  a  spouting  of  blood  in  jets  from 
a  few  larger  arteries,  and  a  more  or  less  general  oozing  from  the 
smaller  vessels  and  capillaries.  The  hemorrhage  from  the  larger 
arteries  having  been  arrested,  and  that  from  the  smaller  having 
ceased  spontaneously,  the  wound,  if  accurately  closed,  and  kept 
aseptic  and  at  rest  with  its  surfaces  in  contact,  will  unite  without 
suppuration  by  a  process  of  simple  or  adhesive  inflavimaiion. 
Thus,  the  edges  of  the  wound  for  the  first  day  or  two  may  present 
a  very  faint  blush  of  redness  extending  for  a  few  lines  to  perhaps 
in  a  large  wound  half  an  inch  or  so  beyond  the  incision  ;  whilst 
they  may  be  slightly  swelled,  a  little  hotter  than  natural,  and  ten- 
der on  pressure,  but  cjuite  devoid  of  pain.  I'he  redness,  swelling 
and  heat,  however,  may  be  so  slight  as  to  be  almost  impercepti- 
ble, or  indeed  may  be  said  in  some  instances  not  to  occur.  If 
an  attempt  were  now  made  to  draw  the  edges  apart,  they  would  be 
found  adherent  to  each  other,  and  a  few  days  later  firmly  united. 


PROCESS    OF    REPAIR    IN    WOUNDS.  IO5 

All  trace  of  redness  and  swelling  about  the  edges  will  by  this  time 
have  disappeared,  a  red  streak  only  remaining  to  mark  the  line  of 
the  wound.  This  streak  grows  paler  and  paler,  till  ultimately  a 
thin  white  line,  which  in  course  of  time  may  become  hardly 
perceptible,  alone  indicates  the  site  of  the  injury.  The  above- 
mentioned  process,  which  should  be  attended  by  little  or  no  con- 
stitutional disturbance,  is  known  as  healing  by  the  first  intention, 
and  is  the  one  which,  other  things  being  equal,  is  always  aimed  at 
by  the  surgeon  in  the  treatment  of  wounds.  Should,  however,  the 
wound  not  admit  of  its  surfaces  being  placed  wholly  in  contact,  or 
should  it  be  improperly  drained  and  not  kept  aseptic,  the  inflam- 
matory redness  and  swelling  of  the  edges,  instead  of  subsiding 
and  disappearing  in  a  few  days,  will  increase  and  extend  for  some 
distance  around  ;  the  parts  then  become  tense,  there  may  be 
throbbing  pains,  union  fails,  and  suppuration  is  set  up.  In  the 
meantime  the  patient  may  have  a  chill  or  even  a  distinct  rigor; 
the  temperature  rises ;  the  pulse  is  increased  in  frequency  ;  the 
tongue  becomes  coated,  the  skin  hot  and  dry,  the  urine  scanty  and 
high  colored,  and  the  bowels  confined  ;  he  complains  of  headache 
and  loss  of  appetite,  and  there  may  be  restlessness  and  want  of 
sleep  and  perhaps  slight  delirium  {septic  traumatic  fever).  If  now 
a  free  exit  is  established  for  the  pus,  and  further  septic  changes 
are  prevented,  the  constitutional  disturbance  subsides,  and  the 
surface  of  the  wound  becomes  covered  with  granulations.  The 
granulations  gradually  fill  up  the  wound,  and  when  the  level  of 
the  skin  or  mucous  membrane  is  reached,  epithelium  slowly 
spreads  from  the  edges  of  the  wound  over  the  granulations  till 
they  are  completely  covered  in.  A  red  scar  is  thus  left  at  the 
seat  of  the  former  wound,  and  though  this  in  the  process  of  time 
assumes  a  white  color,  and  becomes  smaller  from  the  contraction 
of  the  fibrous  tissue  into  which  the  granulations  are  at  length 
converted,  it  is  of  a  permanent  character.  The  above  method  of 
repair  is  known  as  healing  by  the  second  intention,  or  by  granula- 
tion. 

In  wounds  where  there  is  loss  of  substance,  so  that  the  edges  of 
the  skin  cannot  be  brought  into  contact,  healing  by  the  second 
intention  is  the  normal  method  of  union.  The  surface  after  the 
hemorrhage  has  been  stopped  becomes  glazed  over,  and  a  reddish 
serum  slowly  escapes  ;  granulations  appear,  first  here  and  there, 
and  finally  over  the  whole  surface  of  the  wound,  which  is  then 
gradually  filled  up  as  described  above.  In  lacerated  wounds  the 
same  process  occurs,  the  dead  portions  of  the  lacerated  tissues, 
howeverj  being  first  thrown  off  in  the  form  of  sloughs.  In  flap 
wounds  where  adhesion  by  the  first  intention  has-  failed,  after  the 
surfaces  of  the  flaps  have  become  covered  by  granulations  the  two 


io6 


GENERAL    PATHOLOGY    OF    INJURIES. 


layers  of  granulations  in  contact  may  unite,  a  mode  of  healing 
known  as  secondary  adhesion  or  union  by  the  third  intention.  Yet 
again,  when  a  wound  has  been  sealed  by  blood  or  discharges,  it 
may  unite  either  by  adhesive  inflammation  or  by  granulation,  the 
process  being  hidden  by  the  scab  of  hardened  blood  and  dis- 
charges, on  the  separation  of  which  the  wound  is  found  soundly 
healed.  It  is  the  common  method  of  healing  among  animals, 
and  is  known  as  healing  under  a  scab,  or  as  it  was  humorously 
described  by  Sir  James  Paget  in  his  lecture  on  Surgery,  as  union 
by  no  intention  at  all. 

Thus  a  wound  may  heal,  i,  by  adhesive  inflammation,  or  by  the 
first  intention  ;  2,  by  granulation,  or  by  the  second  intention  ;  3, 
by  secondary  adhesion,  union  of  granulations,  or  by  the  third  in- 
tention ;  and  4,  under  a  scab.  These  methods  of  healing  may 
now  be  studied  more  in  detail. 

I.  Healing  by  the  first  intention,  or  by  adhesive  inflammation. — 
Chiefly  as  the  result  of  the  injury  inflicted  on  the  tissues  by  the  in- 
strument making  the  wound,  and  to  a  less  extent  as  the  result  of 
exposure  to  the  cold  air  and  it  may  be  of  the  irritation  of  strong 
chemical  antiseptics,  a  simple  traumatic  inflammation  is  set  up 


Fig.  22. 


Fig.  23. 


■la* 


Wir?- 


mr^ 


Diagram  representing  a  simple 
incifed  wound,  immediately  af- 
ter the  incision  has  been  made. 


Diagram  representing  an  incised  wound 
a  few  hours  after  the  incision.  A. 
Area  of  thrombosis — leucocytes  mak- 
ing their  way  to  tlie  cut  surface.  B. 
Area  of  dilated  capillaries — leticocytes 
escaping  from  the  vessels  into  the  tis- 
sues.    C.  Normal  tissues. 


in  the  layer  of  tissue  bounding  the  incision  (Fig.  22  and  Fig.  23). 
As  a  consec|uence,  stasis  and  coagulation  of  the  blood  is  induced 
in  the  divided  smaller  vessels  and  capillaries,  and  thus  the  hemor- 
rhage from  them  spontaneously  ceases  (Fig.  23).  Immediately 
around  there  is  dilatation  of  the  vessels  with  retarded  flow,  and 
proliferation  of  the  connective  tissue  cells,  escape  of  leucocytes 
and  liquor  sanguinis.  These  infiltrate  the  tissues  adjacent  to  the 
incision,  and  pass  through  the  cut  lymph-spaces  on  to  the  raw  sur- 


PROCESS    OF    REPAIR    IN    WOUNDS. 


107 


face  of  the  wound.  There  coagulation  occurs,  the  fibrin  and  the 
entangled  corpuscles  forming  a  layer  of  coaguable  lymph  between 
the  surfaces  of  the  wound,  whilst  the  serum,  at  first  red  from  the 
presence  of  red  corpuscles  but  subsequently  becoming  colorless, 
drains  gradually  away.  It  is  this  coagulable  lymph  which  causes 
the  surfaces  of  the  wound  after  the  first  few  hours  to  adhere,  or  to 
become  glazed  if  the  wound  is  kept  open  for  some  time  before  the 
edges  are  approximated,  as  was  formerly  a  not  uncommon  prac- 
tice. A  little  further  from  the  line  of  incision  there  is  the  usual 
inflammatory  phenomenon  of  dilated  vessels  with  accelerated  flow 
(Fig.  23),  thus  accounting  for  the  faint  blush  of  redness  and  the 
slight  swelling  about  the  edges  of  the  wound.  The  coagulable 
lymph  uniting  the  surfaces  of  the  wound,  together  with  the  tissues 
immediately  adjacent  to  the  incision,  next  become  softened  and 
finally  replaced  by  the  infiltrating  leucocytes  and  proliferating 
connective  tissue  cells  which  now  form  a  layer  of  small  round 
cells,  welding  as  it  were  the  surfaces  of  the  wound  together  (Fig. 
24) .  The  inflammation,  like  all  inflammations  of  traumatic  origin, 
tends  to  cease  as  soon  as  the  cause  is  removed.  Thus  in  a  day 
or  two  it  subsides,  and  if  a  section  of  the  parts  were  now  made, 
the  uniting  layer  of  small  round  cells  could  be  seen  permeated  by 


Fig.  24. 


Fig. 


Diagram  of  an  incised  wound  a 
day  or  two  after  the  incision. 
The  sides  of  the  wound  united 
by  small  round  cells. 


Diagram  of  an  incised  wound,  a  few 
days  after  the  incision.  Loops  of 
capillaries  growing  out  from  the  old 
capillaries  and  making  their  way 
amongst  the  small  round  cells  unit- 
ing the  cut  surfaces.  A_t  the  lower 
part  of  the  figure  a  loop  has  united 
with  one  from  the  opposite  side. 


delicate  new  capillaries  stretching  across  from  one  side  of  the 
wound  to  the  other  (Fig.  25).  They  are  generally  believed  to  be 
produced  by  loops  growing  out  from  the  old  capillaries,  and  unit- 
ing with  others  similarly  produced,  and  growing  out  from  the 
capillaries  on  the  opposite  side.  This  vascularization  of  the 
uniting  layer  of  cells  accounts  for  the  redness  of  cicatricial  line, 
and  for  the  slight  hemorrhage  which  now  occurs  if  the  edges  of 


io8 


GENERAL   PATHOLOGY   OF   INJURIES. 


the  wound  be  drawn  forcibly  apart.  As  the  capillary  circulation 
is  established,  the  edges  of  the  wound  become  pale  from  the  col- 
lateral vessels  being  now  no  longer  overcharged.  The  granula- 
tion-tissue thus  formed  is  at  length  developed  into  fibrous  tissue, 
which,  like  all  new  fibrous  tissue,  contracts,  obliterating  many  of 
the  newly-formed  vessels.  Hence  the  gradual  paHng  of  the 
cicatrix,  which  now  becomes  practically  non-vascular. 

Healing  by  the  first  intention  may  be  prevented  by — i.  Much 
contusion  of  the  edges  of  the  wound,  with  consequent  death  of 
the  tissues  bounding  the  incision  j  2.  The  presence  of  aseptic 
foreign  body  in  the  wound ;  3.  A  greatly  lowered  vitahty  of  the 
tissues,  as  from  broken  health,  abuse  of  alcohol,  diabetes,  bad 
hygienic  surroundings,  bruising  of  the  parts,  rough  sponging,  or 
use  of  too  strong  antiseptics ;  4.  The  parts  not  being  kept  at 
rest,  with  the  surfaces  of  the  wound  in  accurate  apposition;  5. 
Inefficient  drainage,  whereby  the  serum  squeezed  out  from  the 
coagulating  material  is  allowed  to  collect  in  the  wound  and  cause 
tension  ;  6.  Neglect  of  antiseptic  precautions  and  consequent  de- 
composition of  the  serum,  or  the  infection  of  the  wound  by  some 
of  the  specific  micro-organisms  introduced  either  at  the  time  it 
was  inflicted  or  subsequently.  Under  any  of  the  above  circum- 
stances the  inflammation  may  be  kept  up,  the  pyogenic  micrococci 
may  gain  a  footing,  and  further  infiltration  of  leucocytes  and  pro- 
liferation of  tissue-elements  take  place  ;  the  small-cell-exudation 
uniting  the  wound  then  breaks  down  into  pus,  the  flaps  separate, 
and  suppuration  is  established.  Supposing  the  cause  of  the  in- 
flammation to  be  now  removed,  healing  by  the  second  intention 
will  ensue. 

2.  Healing  by  second  intention. — New  vessels  grow  out  among 

the  layers  of  small  round  cells 
forming  the  exposed  surface  of  the 
wound,  and  granulation-tissue  is 
thus  formed  (Fig.  26).  The 
growth  of  granulations,  other 
things  being  equal,  exceeds  the 
breaking  down  of  the  superficial 
layers  of  cells,  and  the  wound  is 
gradually  filled  up.  Epithelium 
derived  from  the  old  epithelium 
at  the  edges  of  the  wound  gradu- 
ally spreads  over  the  surface  of 
the  granulations ;  but  new  sweat  and  sebaceous  glands,  hair  folli- 
cles, papillae  and  lymphatics,  are  not  formed.  The  cicatrix,  at 
first  red  from  the  abundance  of  the  capillaries  in  the  granulation 
tissue,  becomes  pale  as  these  are  obliterated  by  the  contraction  of 


Fig.  26. 


^^^mm^ 


Uiagram  of  Granulating  Wound. 


TREATMENT   OF   WOUNDS.  109 

the  fibrous  tissue  into  which  the  granulation-tissue  is  converted, 
and  though  in  the  course  of  time,  in  consequence  of  the  fibrous 
contraction,  it  becomes  smaller,  a  permanent  scar  will  remain. 

In  wounds  attended  with  loss  of  substance,  in  which  healing 
by  the  second  intention  is  the  normal  process,  a  traumatic  inflam- 
mation is  set  up  in  the  tissues  immediately  adjacent  to  the  surface 
of  the  wound,  and  the  conditions  for  healing  being  otherwise 
favorable,  a  coagulable  material,  as  described  above,  is  formed 
over  the  surface,  and  the  serum  drains  away.  Loops  of  new 
capillaries,  derived  from  the  old,  spring  up  amongst  the  cells,  re- 
placing the  coagulable  exudation  and  softened  adjacent  tissues, 
and  the  wound  heals  and  cicatrizes,  as  has  just  been  described. 
Where  there  is  much  laceration  or  contusion  of  the  surface  of  the 
wound,  the  dead  tissues  are  cast  off  by  ulceration  in  the  way  men- 
tioned under  gangrene. 

3.  Healing  by  the  third  intention. — When  the  two  layers  of 
granulations  covering  the  flaps  of  the  wound  are  placed  and  kept 
in  contact,  the  capillaries  in  the  one  layer  meet  with  those  in  the 
other,  and  so  establish  a  vascular  connection  between  the  two 
flaps,  and  the  heahng  of  the  wound  then  proceeds  in  the  way  de- 
scribed under  union  by  the  first  intention. 

4.  Healing  tinder  a  scab. — The  minute  changes  of  healing  under 
a  scab  require  no  special  description. 

Treatment  of  wounds. — The  general  principles  which  should 
guide  us  in  the  treatment  of  wounds  will  be  considered  under  the 
following  heads  :  i.  Arrest  of  haemorrhage;  2.  Cleansing  of  the 
wound  and  removal  of  foreign  bodies;  3.  Drainage;  4.  Closing 
the  wound  and  keeping  it  subsequently  at  absolute  rest;  5.  Pre- 
vention of  putrefaction,  fermentation,  and  infective  processes  ; 
and  6.  Constitutional  treatment. 

1.  The  arrest  of  hcemorrhage  is  considered  separately  at  p.  128. 

2.  The  cleansing  of  the  wound  and  removal  of  foi'eign  bodies, 
should  be  done  with  all  gentleness,  so  as  not  to  bruise  the  tissues 
more  than  can  possibly  be  avoided,  their  vitality  being  already 
lowered  by  the  incision  through  them.  Thus  the  wound  should 
not  be  sponged  or  nibbed  more  than  is  absolutely  necessary,  but 
a  stream  of  water  previously  boiled,  or  if  preferred,  containing 
some  mild  antiseptic,  allowed  to  run  through  it  to  wash  away  any 
blood-clot,  or  in  the  case  of  accidental  wounds  any  dirt  or  other 
foreign  substance  that  may  have  gained  admission.  If  the  wound 
is  deep  or  irregular,  it  should  be  irrigated,  care  being  taken  when 
the  skin  wound  is  small,  not  to  cause  any  forcible  distension,  for 
fear  of  driving  the  fluid  into  the  interstices  of  the  tissues,  where  it 
may  act  as  an  irritant  and  set  up  inflammation.  Foreign  bodies, 
as  glass,  splinters,  bullets,  etc.,  if  lodged  in  the  wound,  should  be 
picked  out  by  forceps  or  other  suitable  instrument. 


no  GENERAL   PATHOLOGY   OF    INJURIES. 

3.  Drainage. — Where  a  wound  is  quite  superficial,  and  in  some 
situations  where  the  parts  are  very  vascular,  as  about  the  face, 
and  for  moderate-sized  wounds,  in  which  the  surfaces  can  be  kept 
in  contact  by  pressure,  drainage  is  not  necessary.  Such  wounds 
may  be  completely  closed  if  clean  cut  and  moderately  small,  or  a 
stitch  may  be  omitted  at  one  end ;  or  a  loop  of  pewter  wire  in- 
serted, but  only  deep  enough  to  keep  the  edges  of  the  skin  apart 
at  that  place.  If,  however,  the  wound  is  large  or  irregular  or 
lacerated,  and  the  surfaces  cannot  be  kept  in  contact,  efficient 
drainage  of  the  wound  is  of  the  greatest  importance.  Its  object 
is  to  promote  the  free  escape  of  the  serum,  which,  as  we  have 
seen,  is  squeezed  out  during  the  first  twenty-four  hours  from  the 
coagulable  exudation  formed  upon  the  surface  of  the  divided  tis- 
sues as  the  result  of  the  traumatic  inflammation.  If  this  serum  is 
allowed  to  collect  in  the  deeper  parts  and  irregularities  of  the 
v,'ound,  it  not  only  mechanically  separates  the  surfaces,  and  gives 
rise  to  tension,  a  cause  in  itself  of  the  continuance  of  inflamma- 
tion, and  hence  of  the  non-healing  of  the  wound,  but  it  is  also 
liable  to  undergo  decomposition  and  putrefaction,  and  forms  a 
suitable  nidus  for  the  growth  of  pyogenic  micro-organisms.  Now 
the  coagulable  exudation,  being  living  tissue,  resists  the  agents 
which  determine  putrefaction.  Not  so  the  serum.  In  this  we 
have  a  fluid  containing  dead  animal  matter,  and  as  the  other  con- 
ditions favorable  for  decomposition  are  also  present,  viz.,  a  tem- 
perature of  about  100°,  and  a  sufficient  supply  of  water  and  oxy- 
gen, the  addition  of  a  ferment  only  is  required  to  set  it  up.  If 
decomposition  or  fermentation  then  is  suffered  to  take  place 
through  not  keeping  the  wound  aseptic,  or  the  pyogenic  micro- 
cocci are  allowed  to  enter,  the  freshly  divided  tissues,  not  as  yet 
sealed  by  traumatic  inflammation,  permit  the  products  of  decom- 
position or  of  the  micrococci  to  soak  into  the  tissues  around,  set- 
ting up  locally  a  septic  or  spreading  inflammation,  whereby  the 
coagulable  exudation,  temporarily  holding  the  surfaces  of  the 
wound  in  apposition,  is  destroyed,  and  healing  by  the  first  inten- 
tion is  prevented.  In  the  meantime  the  products  of  decom])osi- 
tion  may  pass  into  the  blood,  and  give  rise  to  the  constitutional 
state  known  as  septic  traumatic  fever,  or  if  the  dose  of  the  poison 
is  large,  to  saprsemia  or  septic  intoxication  ;  and  this  is  the  more 
likely  to  occur  if  the  wound  has  been  closed,  so  that  the  decom- 
])osing  serum  is  pent  up  under  some  degree  of  tension.  If  there- 
fore the  wound  is  very  large,  and  deep  or  lacerated  or  irregular,  a 
drainage  tube  or  tubes  should  be  placed  in  it,  and  brought  out  at 
the  most  dependent  part,  the  incisions,  if  the  wound  is  made  in 
an  operation,  being  so  planned  as  to  allow  as  much  as  possible  of 
a  dependent  drain.     For  smaller  wounds  it  may  be  sufficient  to 


TREATMENT    OF    WOUNDS.  Ill 

place  in  them  a  leash  of  horsehair  or  catgut,  a  piece  of  gutta- 
percha tissue,  or  a  strand  or  two  of  pewter  wire.  The  drain-tube, 
if  kept  in  too  long,  will  act  as  a  foreign  body,  set  up  inflammation, 
and  give  rise  to  a  suppurating  sinus  along  its  track.  It  should 
therefore  be  withdrawn  as  soon  as  the  serum  ceases  to  be  squeezed 
out  from  the  coagulating  material — /.  e.,  in  from  twenty-four  to 
forty  eight  hours,  according  to  the  size  of  the  wound.  In  large 
and  deep  wounds  it  is  better  not  to  remove  the  tube  all  at  once, 
as  the  superficial  part  of  the  wound  may  then  heal,  and  the  dis- 
charge or  pus  collect  in  the  deepest  part ;  but  to  shorten  it  grad- 
ually, allowing  the  wound  to  soundly  heal  as  it  is  withdrawn.  The 
drain-tube  should  consist  of  red-rubber  tubing,  varying  in  calibre 
according  to  the  size  of  the  wound.  It  should  have  lateral  holes 
cut  in  it  to  facihtate  the  escape  of  the  discharge,  and  should  be 
made  thoroughly  aseptic  by  being  sterilized  or  boiled,  and  then 
kept  in  some  antiseptic  fluid.  It  had  better  be  passed  through 
the  first  layer  of  dressing,  and  its  mouth  surrounded  by  some  ab- 
sorbent material  to  take  up  the  discharges.  Where  the  wound  is 
deep,  the  tube  should  be  secured  by  a  safety-pin  or  by  an  aseptic 
thread,  lest  it  slip  in,  and  becoming  lost  in  the  depths  of  the  wound, 
subsequently  act  as  a  foreign  body.  Tubes  of  decalcified  bone  have 
been  used  in  the  hope  that  they  would  become  absorbed,  and  so 
prevent  the  necessity  of  disturbing  the  dressings ;  but  they  do  not 
appear  to  have  had  the  desired  effect.  Recently  a  reaction  seems  to 
have  set  in  against  the  use  of  drains  of  all  kinds.  Where  they  are 
dispensed  with  the  skin  wound  is  not  as  a  rule  tightly  closed,  and 
the  deeper  parts  of  the  wound  are  maintained  in  close  apposition 
by  means  of  buried  or  deep  sutures  and  the  application  of  firm 
pressure  over  a  thick  layer  of  absorbent  and  antiseptic  dressing. 

4.  Closure  of  the  wound. — The  surface  should  be  placed  in 
contact,  and  the  edges  accurately  united  by  suture,  strapping,  or 
a  bandage.  Where  the  wound  involves  diff"erent  layers  of  tissue, 
muscle  and  fascia  should  be  united,  each  to  each,  by  aseptic 
sutures.  In  uniting  the  edges  of  the  wound,  care  should  be  taken 
to  see  that  the  skin  is  neither  inverted  nor  everted,  and  that  the 
sutures,  whatever  form  is  used,  are  only  tied  sufficiently  tight  to 
keep  the  edges  in  apposition.  All  tension  should  be  avoided,  as 
this  in  itself  is  a  fertile  cause  of  inflammation.  The  sutures  may 
consist  of  silver-wire,  silk,  catgut,  silkworm  gut,  or  horse-hair. 
All  kinds  have  their  advantages  and  disadvantages,  and  are  var- 
iously required  in  different  cases.  Thus,  silver-wire  is  unirritating 
and  perfectly  non-absorbent,  but  causes  pain  on  removal,  and,  as 
it  is  quite  unyielding,  is  apt,  from  the  swelling  of  the  parts,  to  cause 
tension  and  inflammation  if  left  in  too  long.  Catgut  is  useful  in 
that  its  deeper  parts  become  absorbed,  and  therefore  does  not 


112  GENERAL   PATHOLOGY   OF   INJURIES. 

require  removal.  For  this  reason  it  is  often  inapplicable,  as  it 
gives  way  too  soon.  Catgut  when  chromicized  resists  absorption 
for  many  days,  and  forms  an  admirable  suture.  It  is  difficult, 
however,  to  ensure  it  being  aseptic,  and  is  therefore  abandoned 
completely  by  many  surgeons.  Horse-hair  is  non-absorbent,  and 
is  also  non-absorbable  ;  it  has  the  additional  advantage  of  being 
slightly  yielding  as  well  as  sufficiently  supporting.  It  is  very  use- 
ful when  a  dehcate  suture  is  required,  as  in  wounds  about  the  face. 
Silk  forms  a  strong  suture,  but  possesses  the  disadvantage  of  being 
absorbent  and  thus  of  becoming  saturated  with  the  discharges,  so 
that,  if  decomposition  takes  place,  it  will  act  as  an  irritant. 
Further,  unless  tied  tightly,  in  which  case  it  is  apt  to  produce 
tension,  it  yields  too  much.  At  the  present  day,  however,  fine  silk 
or  china  twist  is,  on  the  whole,  the  favorite  suture.  Sutures  may 
be  made  aseptic  by  boiling  or  by  soaking  for  twenty-four  hours  in 
I  in  500  perchloride  of  mercury  solution.  They  should  then  be 
kept  in  absolute  alcohol  3  parts  and  perchloride  of  mercury 
solution  (i  in  200)  2  parts,  or  they  may  safely  be  kept  in  carbolic 
lotion  (i  in  20). 

The  sutures  are  introduced  by  various  forms  of  surgical  needles, 
curved  and  straight,  bayonet-spear  and  probe-pointed  (Fig.  27), 

Fig.  27.  Fig.  28. 


^^         II  -  ■■  mil— »  Convenient  needle- 

'Cf  Surgical  needles  and  hare-lip  pin. 

the  needle  being  conveniently  passed  by  one  of  the  many  forms  of 
needle-holder  (Fig.  28).  The  methods  of  applying  sutures  are 
very  numerous.  The  two  chief  forms  of  suture  used  in  ordinary 
wounds  are  the  interrupted,  the  suture  being  tied  or  twisted  at 
each  stitch  and  cut  off  short,  and  the  coiitiui/oits,  one  suture  being 
used  throughout  without  being  cut.  Among  the  special  forms  may 
be  mentioned  the  twisted,  the  button,  the  quilled,  the  Lembert, 
the  Jobert,  the  Gely,  and  the  Czerny,  which  are  referred  to  under 
those  wounds  where  they  are  specially  indicated.  The  other 
methods  of  closing  wounds,  as  by  styptic  colloid,  iodcformed 
collodion,  and  collodion,  are  useful  in  wounds  about  the  face,  and 
where  the  wound  is  small.  Having  closed  the  wound,  the  parts 
should  be  placed  as  far  as  is  possible  at  absolute  rest,  and  sup- 


TREATMENT    OF    WOUNDS.  II3 

ported  by  firm  but  elastic  pressure  to  insure  the  deeper  surfaces 
being  in  apposition. 

5.  Preveiition  of pt(t7-ef actio  n^fermeniation,  and  infective  processes 
occurring  in  the  tvound. — Putrefaction  and  fermentation  are  best 
prevented  by  thorough  asepsis,  or  by  efficiently  draining  the 
wound,  or  by  keeping  the  surfaces  in  contact  by  firm  pressure,  as 
there  is  then  no  material  present  in  the  wound  wherein  decomposi- 
tion can  occur.  Antiseptics,  viz.,  agents  that  are  supposed  to 
destroy  septic  and  infective  organisms,  are  adopted  by  many  sur- 
geons as  an  extra  precaution,  and  are  especially  necessar}'  where 
thorough  asepsis  cannot  be  insured,  or  drainage  or  efficient  pres- 
sure, as  in  some  forms  of  compound  fracture,  wounds  of  joints, 
etc.,  cannot  be  employed.  It  is  questioned  by  some  pathologists, 
however,  if  our  so-called  antiseptics  are  efficient  destroyers  of 
micro-organisms  or  their  spores,  unless  used  so  strong  that  they 
endanger  the  vitality  of  the  tissues ;  some  surgeons  trust  therefore 
merely  to  asepsis,  /.  e.,  absolute  cleanliness,  and  have  abandoned 
all  antiseptics. 

But  we  have  to  guard,  not  only  against  the  decomposition  of 
the  discharges,  but  also  against  the  entrance  of  infective  micro- 
organisms, conveyed  by  instruments,  sponges,  the  surgeon's  or 
nurse's  hands,  or  by  the  air  when  an  infectious  case  is  in  the  ward. 
The  greatest  cleanliness  therefore  is  necessary.  All  instruments 
should  be  carefully  cleansed  after  use  before  they  are  put  away, 
and  before  being  used  again  they  should  be  sterilized  by  boiling 
them  in  water  or  in  a  one  per  cent,  salt  solution,  or  by  passing 
them  through  the  flame  of  a  spirit  lamp,  or  placing  them  in  the 
steam  sterilizer.  Whilst  in  use  they  should  be  placed  in  some 
antiseptic  solution,  as  carbolic  acid  (i  in  20)  or  lysol  (2  per 
cent.).  Sponges  except  new  ones  had  better  not  be  used  at  all, 
but  Gamgee's  absorbent  pads,  or  dabs  of  cotton-wool,  which  can 
be  destroyed  immediately  after  the  operation.  New  sponges  after 
cleansing  should  be  kept  in  carbolic  acid  (i  in  20).  The  hands 
of  the  surgeon  should  be  scrupulously  cleaned  by  thoroughly 
washing  in  soap  and  water,  his  nails,  previously  well  pared  down, 
being  cleansed  with  an  aseptic  nail  brush.  They  should  be  then 
further  purified  by  dipping  them  into  carbolic  acid  (i  in  40),  or 
corrosive  sublimate  (i  in  1,000).  Previous  to  the  operation,  the 
part  should  be  shaved,  if  necessary,  and  washed  with  soap  and 
water  for  some  distance  around  where  the  wound  is  to  be  made, 
and  afterwards  with  carbolic  acid  (i  in  20),  or  corrosive  subli- 
mate (i  in  1,000),  and  where  greasy,  with  ether.  An  antiseptic 
dressing  should  then  be  applied  and  kept  on  till  the  patient  is  on 
the  operating  table.  Before  the  dressing  is  removed,  towels  wrung, 
out  in  warm  carbolic  lotion  (i  in  20)  should  be  arranged  around 
5* 


114  GENERAL   PATHOLOGY   OF   INJURIES. 

the  4)art  where  the  wound  is  to  be  made,  so  as  to  prevent  the 
clothes  coming  into  contact  with  the  wound  ;  the  wetting  of  the 
patient's  clothes  being  prevented  by  placing  aseptic  mackintosh 
cloths  beneath  the  carbolized  towels.  In  place  of  carbolic  towels, 
towels  fresh  from  the  sterilizer  are  preferred  by  some  surgeons. 
On  the  removal  of  the  dressing  the  parts  should  be  again  sponged 
with  the  antiseptic — carbolic  lotion  (i  in  40),  or  corrosive  sub- 
limate solution  (i  in  500).  The  carbolic  spray  is  now  abandoned, 
and  irrigation  with  corrosive  sublimate  (i  in  5,000),  carbolic  acid 
(i  in  40),  or  even  boiled  water  substituted  for  it. 

In  a  work  of  this  character,  it  would  be  impossible  to  attempt 
any  description  of  the  numerous  methods  of  dressing  wounds 
which  have  been,  or  are  at  the  present  day,  in  use,  and  to  ade- 
quately discuss  the  advantages  claimed  for  them,  and  the  disad- 
vantages which  all  of  them  to  a  greater  or  less  degree  possess. 
The  objects  aimed  at  in  the  selection  of  a  dressing  are  :  i,  that  it 
should  be  absorbent,  so  as  readily  to  soak  up  the  discharges 
drained  off  from  the  wound  ;  2,  that  it  should  promote  the  drying 
of  the  wound  ;  3,  that  it  should  be  antiseptic  or  aseptic  ;  and, 
hence  4,  that  it  should  not  require  frequent  changing,  since  such 
necessarily  disturbs  the  wound  and  therefore  deprives  the  tissues 
of  that  rest  which  is  so  important  in  promoting  physiological  re- 
pair. The  materials  most  frequently  used  are  gauze  or  cotton- 
wool, impregnated  with  sal  alembroth  or  the  double  cyanide  of 
mercury  and  zinc,  or  simply  sterilized  by  dry  heat  or  superheated 
steam.  My  own  plan  is  to  dress  the  wound  with  several  layers  of 
moist  sal  alembroth  gauze,  over  which  is  placed  dry  gauze  and  a 
thick  layer  of  dry  sal  alembroth  wool.  Where  the  skin  is  very 
irritable  a  layer  or  two  of  iodoform  gauze  is  placed  next  to  it 
beneath  the  other  dressing.  Firm  compression  with  a  bandage 
is  then  applied.  The  wound  is  now  left  absolutely  at  rest  till 
healing  is  thought  to  have  taken  place.  The  temperature  and 
pulse  are,  of  course,  carefully  watched ;  and  should  they  indicate 
any  abnormality  in  the  process  of  healing,  or  should  there  be 
local  pain  or  uneasiness,  the  wound  is  looked  at  and  the  dressings 
re-applied. 

6.  Constitutional  treatment. — Whether  the  wound  is  received 
accidentally,  or  is  inllicted  in  the  form  of  an  operation,  much  of 
the  surgeon's  success  will  depend  upon  j\idicious  constitutional 
after-treatment ;  and,  indeed,  in  the  latter  case,  in  great  measure 
also  upon  the  preparation  of  the  patient.  Where  the  wound  is 
large  and  there  has  been  much  haemorrhage,  the  condition  known 
as  shock,  and  the  constitutional  symptoms  depending  upon  severe 
loss  of  blood,  will  probably  ensue  (see  Shock  and  Hcemon-hai^c). 
For  the  wound  to  do  well  it  is  important  that  the  patient  should 


VARIETIES   OF   OPEN   WOUNDS.  II5 

be  placed  under  the  best  possible  hygienic  conditions.  He 
should  have  an  abundant  supply  of  fresh  air,  the  secretions  should 
be  regulated,  and  the  diet  carefully  supervised.  Thus,  he  should 
have  at  least  fifteen  hundred  cubic  feet  of  air,  and  this  should  be 
changed  by  efficient  ventilation  at  least  three  times  every  hour. 
The  windows,  in  addition,  except  in  very  severe  weather,  should 
be  opened  at  regular  intervals,  in  order  to  thoroughly  flush  out 
the  room  ;  but  draughts  must  be  avoided,  and  the  temperature  of 
the  room  maintained  at  a  uniform  degree  of  about  60°  F.  A 
horsehair  mattress  should  be  employed,  and  a  draw-sheet  placed 
on  the  bed.  The  room  or  ward  should  be  scrupulously  clean  ; 
there  should  be  no  curtains  to  the  bed  and  windows,  or  planned 
carpet  on  the  floor,  and  nothing  under  the  bed  to  interfere  with 
the  free  circulation  of  air.  The  bowels  should  be  kept  regular  by 
small  doses  of  confection  of  senna,  or  of  the  compound  liquorice 
powder,  or  by  one  of  the  laxative  mineral  waters ;  the  secretion 
of  the  skin  promoted  by  washing,  which  may  be  done  without  un- 
duly exposing  or  wetting  the  patient ;  and  sleep  induced,  if 
necessary,  by  bromide  of  potassium,  bromide  of  ammonium, 
paraldehyde,  urethane,  chloral,  sulphonal,  or  opium,  or  by  sub- 
cutaneous injections  of  morphia.  The  patient  must  be  kept 
cheerful  by  books,  newspapers,  etc.  The  diet  for  the  first  few 
days  should  be  limited  to  milk,  weak  beef-tea,  or  chicken-broth, 
and  gradually  increased  if  the  temperature  remains  normal,  and 
as  the  digestive  functions  regain  their  power.  Where  the  strength 
has  been  much  reduced  previous  to  the  operation,  or  the  opera- 
tion has  been  severe,  or  the  shock  marked,  or  haemorrhage  free, 
or  suppuration  has  ensued,  stimulants,  varying  in  amount  accord- 
ing to  the  state  of  the  pulse,  temperature,  and  tongue  are  indi- 
cated. The  treatment  necessary  for  the  various  complications 
that  may  attend  the  heaUng  of  wounds  is  given  under  Inflamma- 
tion, Suppuration,  Erysipelas,  etc.  As  regards  the  preparation 
for  operation,  where  this  is  not  one  of  emergency,  the  patient 
should  be  placed  at  rest  for  a  few  days,  and  kept  cheerful  and  in 
good  spirits,  and  put  on  nourishing  but  unstimulating  diet.  In 
the  meantime  his  digestive,  alvine,  renal,  and  cutaneous  functions 
must  be  regulated  by  appropriate  means,  the  bowels  being  cleared 
the  day  before  the  operation  by  a  dose  of  castor  oil  or  other  mild 
purgative.  Where  his  strength  is  much  reduced  by  long-con- 
tinued suppuration  or  chronic  disease,  efforts  must  be  made  to 
improve  his  general  health  by  nourishing  diet  and  the  judicious 
employment  of  stimulants. 

Varieiies  of  OPEN  WOUNDS. — Open  wounds  are  divided  into 
incised,  lacerated,  contused,  punctured,  and  poisoned. 

Incised  wounds  are  such  as  have  their  edges  evenly  divided  and 


Il6  GENERAL   PATHOLOGY    OF   INJURIES. 

their  surfaces  smoothly  cut.  They  are  usually  inflicted  by  sharp 
instruments,  and  are  those  commonly  made  by  the  surgeon  in 
operating.  The  danger  which  is  particularly  liable  to  attend 
them  is  haemorrhage.  Healing  is  generally  accomplished  by  the 
first  intention,  provided  the  proper  means  are  employed.  Treat- 
ment.— What  has  been  said  under  the  treatment  of  wounds  gen- 
erally, applies  especially  to  this  variety. 

Lacerated  wounds  are  those  in  which  the  tissues  forming  the 
surface  and  edges  of  the  wound  are  irregularly  torn.  They  are 
commonly  caused  by  machinery  and  by  the  goring  and  bites  of 
animals.  There  is  usually  but  little  hgemorrhage,  in  consequence 
of  the  vessels  being  torn  rather  than  cut  across.  The  chief 
dangers  are  profuse  suppuration,  tetanus,  saprsemia,  erysipelas, 
and  extensive  scarring.  Healing  is  generally  accomplished  by  the 
second  intention,  the  dead  portions  of  the  lacerated  tissues  being 
first  thrown  off  by  ulceration  in  the  way  described  under  Gan- 
grene. In  some  situations  and  under  favorable  conditions,  how- 
ever, a  large  part  of  the  wound  may  heal  by  the  first  intention. 
Treatment. — Special  attention  should  be  paid  to  the  cleansing  of 
the  wound  and  establishing  a  free  drain.  Any  portions  of  the 
tissues  which  have  obviously  lost  their  vitality  should  be  cut  away. 
Sutures  should  not  as  a  rule  be  applied,  but  the  wound  should  be 
dressed  by  one  of  the  methods  before  described,  and  the  parts 
placed  at  rest. 

Contused  wounds  are  those  in  which  the  tissues  forming  the 
surface  and  edges  are  extensively  bruised.  They  are  usually 
made  with  blunt  instruments,  or  with  such  agents  as  distribute  the 
force  over  a  large  surface.  There  is  commonly  considerable  ex- 
travasation of  blood  amongst  the  bruised  tissues,  though  usually 
but  little  external  haemorrhage.  The  chief  dangers  are  extensive 
inflammation  and  sloughing,  secondary  haemorrhage  on  the  sepa- 
ration of  the  sloughs,  spreading  gangrene,  erysipelas  or  diffuse  cel- 
lulitis, tetanus,  and,  later,  scarring.  A  combination  of  laceration 
and  contusion  is  frequently  present.  Healing  is  generally  accom- 
plished by  the  second  intention.  The  Treatment  is  similar  to 
that  of  lacerated  wounds.  Any  portions  of  skin  which  have  not 
lost  their  vitality  should  be  preserved,  especially  if  the  wound  in- 
volves the  face  or  scalp. 

Punctured  wounds  are  those  in  which  the  depth  is  much  greater 
than  the  breadth.  They  are  usually  ])roduced  by  sharp-pointed 
instruments,  bayonet  or  sword-thrusts,  and  stabs.  The  chief 
dangers  are  haemorrhage,  penetration  of  important  cavities,  as  the 
thorax,  abdomen,  or  a  joint,  injury  of  a  large  blood-vessel  or 
nerve,  and  subsequently  deep  suppuration  in  consequence  of  the 
retention  of  the  discharges  in  the  deep  portion  of  the  wound. 


POISONED   WOUNDS.  II  7 

Punctured  wounds  usually  unite  by  the  second  intention,  owing  to 
the  difificulty  of  keeping  the  deeper  parts  of  the  wound  in  contact 
and  of  preventing  the  collecting  of  serum  and  later  of  pus. 
Treatment. — If  deep,  a  drainage-tube  should  be  passed  to  the 
bottom  of  the  wound,  and  gradually  shortened  as  the  wound 
heals.  If  there  is  severe  arterial  haemorrhage  which  cannot  be 
controlled  by  carefully  applied  pressure,  the  wound  must  be  con- 
verted into  an  incised  one,  and  the  bleeding  vessel  treated  in  the 
way  described  under  wounds  of  arteries,  veins,  etc.  For  the 
special  treatment  required  where  a  joint  or  visceral  cavity  has 
been  penetrated,  see  Injuries  of  Regions. 

Poisoned  wounds. — Dissection  and  post-mortem  wounds. — Dis- 
section wounds  are  of  frequent  occurrence,  but  seldom  give  rise  to 
any  serious  trouble,  unless  the  body  from  which  the  poison  is 
received  is  fresh,  when  the  risks  are  similar  to  those  attending 
wounds  received  in  making  post-morte?7i  examinations.  Fost- 
jnortem  wounds  appear  to  owe  their  virulence  to  inoculation  with 
infective  micro-organisms  which  are  capable  of  multiplying  in  the 
tissues  or  in  the  blood,  and  so  setting  up  true  infective  inflamma- 
tion and  blood-poisoning.  The  micro-organisms  are  replaced,  as 
the  decomposition  of  the  corpse  sets  in,  by  the  bacteria  of  putre- 
faction. Hence,  the  longer  the  body  has  been  kept  the  less  dan- 
gerous the  wound,  as  these  bacteria  are  merely  capable  of  induc- 
ing a  local  inflammation,  and  not  a  true  infective  process.  The 
most  dangerous  wounds  are  those  received  whilst  examining  bodies 
in  which  death  has  recently  resulted  from  septicaemia,  pyaemia, 
diffuse  or  puerperal  peritonitis,  and  erysipelas.  The  effects  of  a 
wound  received  in  dissection,  or  in  post-mo?'tem  inspection,  will 
depend  in  some  degree  upon  the  health  of  the  operator  ;  if  strong 
and  vigorous  he  is  better  able  to  resist  the  toxic  effects  than  when 
debilitated  by  prolonged  study  or  work  in  a  hospital  ward.  On 
the  other  hand,  persons  acchmatized  to  the  dissecting  or  post- 
mortem room  are  less  liable  to  be  affected  than  those  who  have 
but  recently  been  engaged  there. 

The  signs,  as  might  be  expected  from  what  has  been  said 
above,  vary  considerably,  depending,  as  they  do,  upon  the  nature 
of  the  poison  received  from  the  corpse,  and  the  previous  state  of 
the  operator's  health.  Thus  :  i.  A  pustule  may  form  at  the  seat 
of  inoculation,  and,  after  breaking  and  scabbing,  leave  a  raised, 
indolent,  painful  red  sore,  which  may  exist  for  months  in  spite  of 
treatment.  2.  The  scratch  or  wound  may  become  inflamed,  the 
superficial,  and,  perhaps,  the  deep  lymphatics  implicated,  and  the 
axillary  glands  enlarged  and  painful,  this  condition  being  attended 
by  sharp  constitutional  disturbance,  often  preceded  by  a  rigor. 
Suppuration  generally  occurs  at  the  seat  of  inoculation,  and  some- 


Il8  GENERAL    PATHOLOGY    OF    INJURIES. 

times  also  in  the  axillary  glands.  The  prognosis  is  usually  good. 
3.  With  or  without  the  local  signs  of  the  preceding  form,  severe 
constitutional  symptoms  may  set  in,  preceded  by  a  rigor,  and 
rapidly  assume  a  typhoid  character.  Diffuse  suppuration  occurs 
in  the  axillary  glands,  and  may  spread  to  the  neck  and  side  of 
the  chest.  The  prognosis  is  very  unfavorable,  the  patient  often 
dying  in  from  one  to  three  weeks,  or  only  recovering  after  a  tedi- 
ous convalescence,  and  then,  probably,  wdth  a  broken  constitu- 
tion. 4.  Diffuse  cellular,  or  cellulo-cutaneous  erysipelas,  may  be 
set  up  at  the  seat  of  inoculation,  attended  with  the  usual  constitu- 
tional symptoms  of  these  affections,  and  may  rapidly  spread  up 
the  limb  and  terminate  in  gangrene  and  death.  The  axillary 
glands  in  this  form  are  not  usually  affected.  5.  In  addition  to 
the  local  suppuration,  a  pytemic  state,  with  the  formation  of 
metastatic  abscesses  in  various  tissues  and  organs,  sometimes 
occurs. 

Treatment — Immediately  on  its  infliction  the  wound  should  be 
sucked,  and  cleansed  by  a  stream  of  cold  water,  and  bleeding 
encouraged  and  absorption  prevented  by  tightly  binding  the  part 
above  the  wound.  Where  the  corpse  is  recent,  and  death  is 
known  to  be  the  result  of  some  infective  disease,  the  wound  should 
be  washed  in  strong  carbolic  or  corrosive  sublimate  lotion  (some 
recommend  its  cauterization  with  caustic  potash,  or  nitrate  of 
silver),  and  then  dressed  and  protected  from  further  infection.  If 
a  wart  or  indolent  sore  form,  it  should  be  destroyed  by  nitrate  of 
silver,  acid  nitrate  of  mercury,  or  other  caustic,  and  the  patient's 
health  improved  by  tonics  and  change  of  air.  If  an  infective  in- 
flammation be  set  up,  the  wound  should  be  freely  incised,  and  any 
abscess  that  may  form  in  the  axilla,  or  elsewhere,  opened  early ; 
indeed,  if  there  is  much  tension  or  brawniness  of  the  parts,  inci- 
sions should  be  made  before  pus  has  formed.  The  bowels  in  the 
meantime  should  be  cleared  by  a  brisk  purge,  and  the  strength 
supported  by  nourishment  and  stimulants. 

Siini^s  of  insects  sometimes  cause  troublesome  local  inflamma- 
tion, which  is  occasionally  of  a  diffuse  character,  and  where  a 
large  extent  of  surface  is  stung,  as  by  a  swarm  of  bees,  may  be 
attended  with  symptoms  of  severe  depression.  Stings  of  the 
throat  occasionally  occur  from  swallowing  a  wasp,  and  are  liable 
to  be  followed  by  oedematous  laryngitis.  Ti-eatment. — The  appli- 
cation of  ammonia  will  at  once  relieve  pain.  Where  there  is 
severe  depression,  ammonia  or  alcohol  must  be  administered. 
Scarification,  intubation  of  the  glottis,  or  even  laryngotomy,  may 
become  necessary  in  severe  stings  of  the  throat. 

Snake-bites. — The  bites  of  poisonous  snakes,  other  than  the 
adder,  are  fortunately  rare  in  this  country.     The  bite  of  the  com- 


CONTUSIONS   OR   BRUISES.  II9 

nion  adder  is  seldom  fatal.  It  is  attended  with  much  collapse, 
nausea  or  vomiting,  great  pain  in  the  part,  swelling  of  the  affected 
member,  subsequent  discoloration  from  blood  extravasation,  and 
occasionally  inflammation  and  suppuration.  The  treatment  con- 
sists  in  sucking  the  part  where  practicable,  applying  a  bandage 
tightly  above  the  bite  to  prevent  absorption  of  the  poison,  and 
the  internal  administration  of  stimulants.  The  local  application 
of  liquor  potassse  or  permanganate  of  potash,  the  injection  of 
ammonia  into  the  veins,  and  excision  of  the  bitten  part,  are 
recommended.  For  an  account  of  the  more  serious  symptoms 
attending  the  bite  of  the  cobra  and  other  venomous  serpents  of 
tropical  countries,  a  larger  work  must  be  consulted. 

Subcutaneous  wounds. — A  wound,  whether  it  be  of  the  con- 
nective tissue,  bone,  muscle,  tendon  or  other  structure,  is  said  to 
be  subcutaneous  when  the  skin  or  mucous  membrane  remains 
intact.  Such  wounds  differ  from  the  open  in  that  they  heal  by 
adhesive  inflammation  v,'ithout  suppuration,  since  as  long  as  the 
skin  or  mucous  membrane  covering  the  wounded  part  is  un- 
broken, septic  processes  are  effectually  prevented.  Moreover, 
they  are  attended  by  but  little,  if  any,  constitutional  disturbance. 
They  will  be  further  described  under  Ritptiwe  of  muscles  and 
tendons,  Simple  Fractures,  etc. 

Diseases  of  cicatrices. — The  cicatrices  left  on  the  healing  of  a 
wound  are  liable  to  certain  affections,  which  may  be  enumerated 
as: — I,  painful  cicatrix;  2,  depressed  or  contracted  cicatrix;  3, 
warty  cicatrix  ;  4,  thin  cicatrices  ;  5,  ulceration  ;  6,  keloid,  and  7, 
epithelioma,  and  more  rarely  sarcoma.  See  Ulceration,  Tumors, 
etc. 

contusions  or  bruises. 

Contusions  are  subcutaneous  injuries,  occasioned  by  a  crush- 
ing, pulping  or  tearing  of  the  tissues,  combined  with  extravasa- 
tion of  blood  consequent  upon  the  rupture  of  the  capillaries  and 
smaller  vessels  of  the  part.  In  their  slighter  forms  they  constitute 
the  common  injury  known  as  a  bruise.  The  effused  blood  gen- 
erally makes  its  way  in  the  cunnective-tissue  planes  towards  the 
skin,  giving  rise  to  the  characteristic  purplish-black  appearance, 
and,  as  it  later  breaks  dovvn  and  becomes  absorbed,  to  a  change 
of  colors  from  bluish-black  through  dark  red  to  yellowish-green. 
In  severe  cases  the  cuticle  is  raised  into  bullge  by  the  eflusion  of 
blood-stained  serum  beneath  it.  These  bullae,  together  with  the 
black  color  of  the  part,  may  occasion  a  close  resemblance  to  gan- 
grene, from  which,  however,  a  contusion  may  be  distinguished  by 
there  being  no  loss  of  heat  or  of  sensation  in  the  part,  and  by  the 
buUpe  being  fixed,  and  not  changing  their  position  on  pressure,  as. 


I20  GENERAL   PATHOLOGY   OF   INJURIES. 

in  gangrene.  In  very  severe  and  extensive  contusions,  however, 
the  tissues  may  be  so  injured  as  to  lose  their  vitaUty,  and  gan- 
grene actually  ensue  ;  whilst  in  other  instances  inflammation  and 
suppuration  may  occur.  When  the  contusion  is  localized,  blood 
to  a  considerable  amount  may  be  poured  out  at  the  injured  spot, 
forming  a  fluctuating  swelling  known  as  a  hcematoma.  Contusions 
of  muscle,  bone,  blood-vessels,  and  nerves,  and  contusions  of  the 
viscera,  are  considered  separately  under  Injuries  of  Special  Tissues 
and  Organs. 

Treatment. — Beyond  placing  the  part  at  rest,  and  applying  an 
evaporating  or  a  spirit  lotion,  nothing  more  as  a  rule  is  required, 
as  the  extravasated  blood  presses  upon  the  injured  vessels,  and 
so  prevents  further  haemorrhage.  Should  a  hsematoma  form,  it 
should  on  no  account  be  opened,  as  the  blood  will  usually  become 
absorbed  ;  whilst,  if  air  be  admitted,  suppuration  will  probably 
ensue.  Aspiration,  however,  when  the  hsematoma  is  very  large, 
may  occasionally  be  done  with  advantage. 

BURNS    AND    SCALDS. 

Burns  and  scalds  vary  in  their  effect  according  to  their  depth, 
extent,  situation,  and  the  age  of  the  patient.  An  extensive  though 
superficial  burn  on  the  trunk,  head,  or  face,  especially  in  a  child, 
may  be  more  serious  than  a  deeper  but  limited  burn  on  the  ex- 
tremities. A  burn  is  usually  said  to  be  more  severe  than  a  scald, 
as  the  fluid  producing  the  latter  generally  quickly  cools  and  runs 
off.  A  scald,  however,  owes  its  severity  to  the  large  extent  of 
surface  usually  implicated,  and  when  produced  by  molten  metal  or 
boiling  oil,  which  adheres  to  the  part,  is  generally  very  serious. 
Burns  and  scalds,  when  severe,  give  rise  to  constitutional  as  well 
as  local  effects.  The  local  effects  may  be  considered  under 
Dupuytren's  division  of  burns  into  six  degrees.  These  degrees, 
however,  may  be  variously  combined  in  the  same  burn. 

1ST  DEGREE. — Simple  erytliema,  due  to  increased  flow  of  blood 
through  the  dilated  vessels.  No  tissue  destruction  ensues,  and  no 
scar  is  left. 

2ND  DEGREE. —  Vesication,  due  to  the  exudation  from  the  dilated 
capillaries  of  the  cutis,  causing  the  superficial  layers  of  the  epithe- 
lium to  be  raised  from  the  deeper  in  the  form  of  blebs.  No  scar 
is  left,  as  only  the  superficial  layers  of  the  epithelium  are  de- 
stroyed, and  these  are  soon  reproduced  from  the  deeper  layers. 
Some  slight  staining  of  the  skin,  however,  may  subsequently  re- 
main. 

3RD  de(;ree. —  Destruction  of  the  cuticle  and  part  of  the  ti'ue 
skin. — The  epithelium  around  the  hair-follicles,  in  the  sweat- 
glands,  and  between  the  papillae,  escapes,  and  rapidly  forms  new 


BURNS  AND   SCALDS.  121 

epithelium  over  the  granulating  surface  left  on  the  separation  of 
the  sloughs.  A  scar  results,  but  as  it  contains  all  the  elements  of 
the  true  skin,  the  integrity  of  the  part  is  retained,  and  hence  there 
is  no  contraction.  It  is  the  most  painful  form  of  burn,  as  the 
nerve-endings  are  involved  but  not  destroyed. 

4TH  DEGREE. — Destruction  of  the  whole  skin. — The  sloughs  are 
yellowish-brown  and  parchment-like,  and  their  separation  is  at- 
tended by  much  suppuration.  As  the  nerve-endings  are  com- 
pletely destroyed,  the  pain  is  much  less  than  in  the  former  degree 
of  burn.  The  epithelium  which  covers  in  the  granulating  surface 
is  only  derived  from  the  margins  of  the  burn,  and  the  resulting 
scar  consists  of  dense  fibrous  tissue.  Hence  the  extensive  con- 
traction and  great  deformity  which  often  result. 

5TH  DEGREE. — Penetration  of  the  deep  fascia  and  implication  of 
the  muscles. — Great  scarring  and  deformity  necessarily  follow. 

6th  DEGREE. —  Charring  of  the  ivhole  limb. — The  parts  are  sep- 
arated by  ulceration  in  the  same  way  as  in  gangrene. 

Constitutional  effects. — When  the  burn  is  superficial  and 
of  small  extent,  there  may  be  no  constitutional  symptoms ;  and 
even  when  it  is  deep,  but  limited  to  one  of  the  extremities,  as  the 
foot  or  hand,  they  may  also  be  slight.  When,  however,  the  burn 
is  extensive,  and  especially  when  it  involves  the  chest,  abdomen, 
or  head  and  neck,  even  although  it  is  only  of  the  first  or  second 
degree,  the  symptoms  may  be  severe,  more  particularly  when  the 
patient  is  a  child.  The  constitutional  effects  may  be  divided  into 
three  stages  : — i.  Shock  and  congestion.  2.  Reaction  and  inflam- 
mation.    3.  Suppuration  and  exhaustion. 

1ST  STAGE. — Shock  and  congestion. — The  shock  is  often  very 
great,  especially  when  the  burn  is  extensive,  and  involves  the 
trunk,  or  head  and  neck.  The  patient  is  pale  and  shivering,  the 
pulse  feeble  and  fluttering,  and  the  extremities  are  cold  ;  he  suffers 
little  or  no  pain,  and  sometimes  passes  into  a  state  of  coma  and 
dies,  the  chief  post-mortem  appearances  being  congestion  of  the 
internal  organs,  particularly  the  brain. 

2ND  STAGE. — Reaction  and  inflammation. — Reaction  comes  on 
from  twenty-four  to  forty-eight  hours  after  the  burn.  The  pulse 
is  full,  strong,  and  rapid,  the  temperature  rises,  and  there  are  other 
symptoms  of  fever.  Inflammation  is  set  up  around  the  burnt  part, 
and  there  is  now  danger  of  the  absorption  of  the  septic  products 
derived  from  the  putrefaction  of  the  sloughs  which  are  beginning 
to  separate.  The  congestion  of  the  internal  viscera,  so  common 
in  the  former  stage,  may  run  into  inflammation  ;  and  pleurisy, 
pneumonia,  peritonitis,  or  meningitis  may  supervene  and  prove 
fatal.  Perforating  ulcer  of  the  duodenum,  which  is  generally 
situated  near  the  head  of  the  pancreas,  may  now  occur,  and  is  said 
6 


122  GENERAL   PATHOLOGY    OF   INJURIES. 

to  be  most  frequently  met  with  about  the  tenth  day.  It  would 
appear  to  be  more  rare,  however,  than  has  been  generally  supposed, 
since  no  case  has  occurred  at  St.  Bartholomew's  during  the  last 
nine  years.  It  has  been  attributed  to  Brunner's  glands  taking 
upon  themselves  the  function  of  the  injured  glands  in  the  burnt 
skin,  and  to  the  irritation  of  the  vitiated  products  secreted  in  the 
bile  and  discharged  into  the  duodenum  at  the  bile  papilla. 

3RD  STAGE. — Suppui'ation  and  exhaustion. — During  this  stage, 
which  sets  in  on  the  separation  of  the  sloughs,  there  is  still  a  dan- 
ger of  the  patient  succumbing  to  inflammation  of  the  viscera, 
especially  the  thoracic ;  or  he  may  be  worn  out  by  hectic  and  ex- 
haustion from  long-continued  suppuration.  He  is  also  exposed  to 
the  risks  of  secondary  hsemorrhage  on  the  separation  of  the 
sloughs  and  to  blood-poisoning  from  the  absorption  of  septic 
products,  unless  the  greatest  care  is  exercised  to  prevent  the 
decomposition  of  the  discharges.  On  cicitrization  occurring,  hor- 
rible deformity  may  ensue  from  the  contraction  of  the  newly- 
formed  fibrous  tissue  in  the  scars. 

The  Treatmeiit  must  be  both  local  and  consdtutional. 

Local  t7-eatment. — The  clothes  should  be  removed  with  the 
greatest  care,  so  as  not  to  tear  off  the  cuticle  ;  but  undue  exposure 
should  be  avoided.  In  burns  of  the  first  and  second  degree  the 
part  should  be  protected  from  the  air  and  changes  of  temperature 
by  smearing  it  with  carron  oil  or  vaseline  and  wrapping  it  in 
cotton-wool,  the  blisters  being  pricked  to  reheve  tension  and  to 
let  out  the  serum.  The  cuticle,  however,  should  not  be  removed, 
as  it  serves  as  the  best  protective.  In  burns  of  the  third  degree, 
the  parts  may  also  be  protected  by  cotton-wool  till  the  sloughs 
begin  to  separate.  Decomposition  of  the  discharges  should  then 
be  prevented  as  much  as  possible  by  mild  antiseptic  dressings. 
Thus,  the  surface  may  be  dusted  with  iodoform  ;  or  eucalyptus  oil, 
boracic  lotion,  and  the  like  may  be  applied.  Some  surgeons  put  on 
a  charcoal  or  even  linseed-meal  poultice.  Carbolic  acid  should  not 
be  used,  as  not  only  is  it  too  irritating,  but  there  is  danger  of  its 
being  absorbed  when  the  burn  is  very  extensive.  When  the 
sloughs  have  separated,  and  granulation  sets  in,  the  wound  may 
be  treated  as  described  under  simple  ulcer,  redundant  granula- 
tions being  repressed  by  nitrate  of  silver.  Skin-grafting  is  often 
usefiil  in  the  fourth  degree  of  burns.  The  fourth  and  fifth  degrees 
re([uire  the  same  treatment  as  the  third,  l)ut  during  cicatrization, 
contraction  must  be  as  far  as  possible  i)revented  by  the  use  of 
elastic  tension,  extension-apparatus,  sjjlints,  etc.  Later  some  forms 
of  plastic  operation  to  overcome  the  effects  of  the  contraction  will 
often  be  required.  \w  the  sixth  degree,  amputation,  if  a  limb  is 
affected,  will  probably  sooner  or  later  be  called  for. 


HEMORRHAGE.  I23 

Constitutional  treatment. — If  the  shock  is  severe,  stimulants  in 
the  form  of  brandy  or  ammonia  should  be  given  according  to  the 
state  of  the  pulse,  the  patient  covered  with  blankets,  hot  bottles 
put  to  the  feet,  and  undue  exposure  whilst  removing  the  burnt 
clothes  and  applying  the  dressings  as  much  as  possible  avoided. 
Opium  should  be  given,  especially  if  there  is  much  pain.  As  soon 
as  the  patient  can  bear  it,  fluid  nourishment  should  be  substituted 
for  stimulants,  as  the  latter,  if  given  in  large  quantities,  only  tend 
to  produce  excessive  reaction  and  inflammation.  During  the 
second  stage,  little  can  be  done  beyond  regulating  the  bowels  and 
secretions  ;  lowering  treatment  is  not  well  borne,  at  any  rate  when 
the  burn  is  extensive  and  deep,  as  the  patient  will  then  require  all 
his  strength  to  sustain  the  drain  on  his  system  during  the  casting 
off  of  the  sloughs  and  the  long  suppuration  following.  The  inflam- 
matory fever,  moreover,  generally  assumes,  if  it  is  not  so  from  the 
first,  a  low  type.  A  stimulating  plan  of  treatment,  rather  than  a 
depressing,  is  therefore  necessary.  In  the  third  stage,  the 
patient's  strength  should  be  supported  by  abundant  nourishment 
and  stimulants. 

Lightning-  and  Electric-stroke. — Death  may  be  instantaneous, 
or  the  stroke,  beyond  causing  temporary  unconsciousness,  may  do 
no  harm.  In  some  instances,  superficial  or  deep  burns,  or 
paralysis  of  certain  nerves,  as  the  optic,  auditory,  etc.,  have  been 
produced.  Of  late  effects  similar  to  those  produced  by  lightning- 
stroke  have  occurred  from  contact  either  with  wires  through  which 
electric  currents  of  high  intensity  were  passing,  or  with  electro- 
motor apparatus.  Death  from  contact  with  such  may  be  due  to 
actual  tissue  destruction,  or  to  arrest  of  respiration  and  asphyxia. 
In  the  first  case  the  subject  is  beyond  recovery  ;  in  the  latter  case 
death  may  be  only  apparent,  and  artificial  respiration  continued 
for  some  hours  may  lead  to  recovery.  The  treatment  consists  in 
applying  warmth,  artificial  respiration,  and  stimulants  whilst  the 
patient  is  in  a  state  of  shock  or  suspended  animation.  Rythmical 
tractions  and  relaxations  of  the  tongue  (the  Laborde  method  of 
treating  asphyxia)  should  be  practiced  by  seizing  the  tongue, 
drawing  it  out  of  the  mouth  and  letting  it  fall  back,  the  process 
being  repeated  about  fifteen  or  twenty  times  a  minute.  The 
functions  of  the  nerves  if  paralyzed  have  sometimes  been  restored 
by  galvanism. 

hemorrhage. 

In  speaking  of  the  treatment  of  wounds  it  was  stated  that  our 
first  care  should  be  to  staunch  haemorrhage.  This  requires  dif- 
ferent measures  according  as  it  is  arterial,  venous,  or  capillary. 
It  is  therefore  first  necessary  to  be  able   to  distinguish  between 


T  24  GENERAL   PATHOLOGY   OF   INJURIES. 

these  varieties.  Usually  it  is  quite  easy.  In  arterial  h(zmorrhage 
the  blood  escapes  in  jets,  the  force  of  which  is  increased  at  each 
systole  of  the  heart,  and  is  of  a  bright  scarlet  color.  In  venous 
hcemorrhage  the  blood  wells  up  from  the  wounded  vessel  usually 
in  a  continuous  stream,  and  is  of  a  dark  purplish-red  color.  In 
capillary  hcemorrhage  the  blood  appears  to  ooze  from  all  parts  of 
the  wound,  trickhng  down  its  sides  to  the  deeper  parts,  where  it 
forms  a  little  pool.  In  some  instances,  however,  as  where  arterial 
blood  escapes  from  a  deep  and  devious  wound,  it  may  resemble 
venous  blood  in  that  it  flows  continuously  instead  of  in  jets,  and 
when  the  patient  is  partially  asphyxiated,  as  from  too  large  a  dose 
of  an  anaesthetic,  it  becomes  of  a  dark  color.  On  the  other  hand, 
venous  blood  exposed  to  the  air  in  its  passage  from  a  deep  wound 
may  undergo  oxygenation  and  become  bright  like  arterial. 
Bleeding  from  the  corpus  spongiosum  and  corpora  cavernosa  of 
the  penis,  or  from  like  tissues  consisting  of  cavernous  blood- 
spaces  or  numerous  small  arteries  and  veins,  is  sometimes  spoken 
oi  2J=>  parenchymatous  iiceniorrhage.  When  haemorrhage  occurs  in 
a  visceral  cavity,  as  the  pleura  or  peritoneum  {internal  hcznior- 
rhage),  or  into  the  substance  of  the  tissues  of  the  trunk  or  ex- 
tremities {extravasation) ,  it  is  known  by  special  signs,  and  is 
treated  of  elsewhere. 

Constitutional  effect  of  hcemorrhage. — The  effect  upon  the  con- 
stitution of  course  varies  according  to  the  amount  of  blood  lost, 
and  is  more  marked  when  the  blood  is  rapidly  poured  out  from  a 
large  artery  than  when  it  escapes  slowly  from  a  small  artery  or 
from  a  vein.  In  the  former  case  the  patient  may  die  in  a  few 
minutes  of  syncope.  When  the  bleeding  is  less  severe  the  face 
and  general  surface  become  blanched  and  cold,  and  the  lips  and 
mucous  membrane  pallid.  The  pulse  is  feeble,  fluttering  and 
rapid,  and  at  length  only  to  be  felt  in  the  larger  vessels.  The 
skin  is  bathed  in  profuse  perspiration,  the  respiration  is  sighing, 
and  the  mind  wanders.  These  symptoms  may  end  in  syncope, 
convulsions,  and  death,  or  the  patient  may  slowly  recover,  or  may 
suffer  from  anaemia  or  functional  disturbances  for  years.  If  he  is 
old,  some  secondary  disease  is  apt  to  be  engrafted  on  this  state  of 
anaemia,  of  which  he  may  die.  Children  bear  the  loss  of  blood 
badly,  but  recover  rapidly  ;  the  old  stand  the  loss  better,  but  the 
effect  on  their  constitution  is  more  permanent. 

Constitutional  treatment  of  hcemorrhage. — When  the  bleeding 
has  been  severe,  immediate  steps  must  be  taken  to  prevent  fatal 
syncope  ;  and  after  this  danger  has  been  tided  over,  we  must  then 
seek  to  counteract  the  remote  effects  produced  upon  the  whole 
system  by  the  loss  of  blood,  i.  Immediate  treatment. — Our  ef- 
forts must  first  be  directed  to  arrest,  or  at  any  rate  to  temporarily 


HAEMORRHAGE.  1 25 

control,  the  hemorrhage  by  some  of  the  local  measures  to  be 
presently  described.  Having  done  this,  the  chief  indication  is  to 
prevent  fatal  syncope  by  ensuring  a  sufficient  supply  of  blood  to 
the  brain  to  excite  the  cardiac  centre  in  the  medulla  oblongata. 
Thus,  the  patient  should  be  laid  on  his  back  with  his  head  low,  his 
body  warmly  covered  up,  and  hot  bottles  placed  at  his  feet  and 
about  his  trunk  ;  or  if  the  pulse  does  not  improve,  stimulants  in 
small  quantities  should  be  administered,  by  the  mouth  if  he  can 
swallow,  otherwise  by  the  rectum  or  by  subcutaneous  injection ; 
whilst  in  severe  cases  the  legs  and  arms  should  be  held  up,  or  an 
Esmarch's  bandage  apphed  to  them  in  order  the  better  to  drive 
the  blood  to  the  brain.  As  a  last  resource,  infusion  of  a  saline 
solution  should  be  practiced.  Where  the  bleeding  is  internal  or 
cannot  be  arrested,  stimulants  should  be  avoided,  inasmuch  as  the 
syncope  into  which  the  patient  has  fallen  tends  temporarily  to 
stop  the  bleeding  by  inducing  clotting  of  the  blood  in  the  wounded 
vessels.  If  the  heart  be  again  roused  to  action  by  stimulants  and 
the  vessels  in  consequence  become  dilated,  the  clots  may  be  dis- 
placed, the  bleeding  re-started,  and  the  last  flickering  spark  of 
life  put  out.  2.  To  counteract  the  remote  ejfects  of  the  loss  of 
blood,  fluid  nourishment  should  be  given  in  small  quantities,  and 
then  eggs,  fish,  and  finally  meat.  Iron  is  required  to  restore  the 
loss  of  hsematin,  and  a  sea-voyage  or  prolonged  residence  in  the 
country  is  beneficial  in  overcoming  the  ansemia. 

Transfusion  of  blood  and  infusion  of  saline  solution  into  the 
veins. — Transfusion  of  blood  has  long  been  employed  in  cases 
where  death  is  threatened  from  excessive  haemorrhage.  It  is, 
however,  a  dangerous  procedure,  in  that  the  transfused  blood  may 
form  clots  and  thus  lead  to  the  plugging  of  some  of  the  patient's 
vessels,  with  possibly  fatal  consequences.  Moreover,  it  appears 
that  blood  is  of  no  more  value  than  an  equal  amount  of  any  bland 
fluid,  since  it  has  been  recently  shown  that  the  transfused  blood 
is  merely  destroyed  and  absorbed  and  the  blood-pigment  passed 
with  the  uiine.  On  the  other  hand,  the  infusion  of  a  saline  solu- 
tion has  all  the  advantages  of  transfusion  of  blood  without  its  dis- 
advantages and  dangers.  A  normal  saline  solution  (common  salt 
•7^)  ;  water  Oj)  at  99°  F.  is  the  most  easily  prepared,  and  is  best 
infused  into  the  median  basilic  vein.  The  vein  is  exposed,  liga- 
tured below,  compressed  above  by  a  clamp,  opened,  and  a  glass 
cannula  introduced  and  secured  in  situ  by  a  ligature.  The 
cannula  is  next  connected  with  an  irrigator  by  a  rubber  tube,  and 
all  air  having  been  carefully  excluded  the  clamp  is  removed  from 
the  vein,  and  several  pints  (2  to  5)  of  the  solution  allowed  to 
flow  in.  A  clean  Higginson's  syringe  connected  with  the  cannula 
by  a  rubber  tube,  will  answer  the  purpose  on  an  emergency  very 


126  GENERAL   PATHOLOGY   OF   INJURIES. 

well.  The  object  of  the  infusion  is  to  raise  the  blood-pressure  in 
the  arteries  sufficiently  to  enable  the  patient  to  rally.  The  pulse 
should  therefore  be  watched,  and  the  infusion  be  continued  till 
the  object  is  attained.  I  have  seen  the  most  marvellous  effects 
follow  this  treatment,  and  many  successful  cases  have  now  been 
reported.  It  may  be  repeated  if  necessary  after  a  short  interval. 
Where  the  apparatus  is  not  at  hand  and  the  case  is  urgent,  a  pint 
of  warm  water  should  be  injected  into  the  rectum  and  prevented 
from  escaping.  The  fluid  is  rapidly  absorbed  from  the  rectum 
and  acts  in  a  similar  manner  to  infusion  into  the  veins,  only  some- 
what more  slowly.  A  half-ounce  packet  of  common  salt,  /.  e., 
sufficient  to  make  four  pints  of  saline  fluid,  a  Higginson's  syringe, 
a  glass  cannula,  and  a  length  of  rubber  tube,  are  desirable  ad- 
ditions as  suggested  by  Mayo  Robson  to  the  surgeon's  bag  when 
severe  haemorrhage  is  likely  to  occur  at  an  operation. 

The  local  treatmeni'  of  haemorrhage  may  be  considered 
under  the  heads  of  arterial,  venous,  and  capillary  haemorrhage. 

Arterial  hemorrhage  is  spoken  of  as  (i)  piimary,  (2)  re- 
actionary or  recurrent,  and  (3)  secondary. 

I.  Primary  hcemorrhage  is  that  which  occurs  at  the  time  an 
artery  is  wounded,  whether  by  accident  or  surgical  operation.  2. 
Reactionary  or  recurrent  hcemorrhage  is  that  which  occurs  on  the 
patient  recovering  from  the  shock  of  the  wound  or  operation  after 
the  primary  haemorrhage  has  stopped,  and  may  be  regarded  as  a 
failure  in  the  process  for  the  temporary  closure  of  the  vessel. 
The  term  recurrent,  therefore,  should  only  be  applied  to  haemor- 
rhage occurring  within  twenty-four  hours  of  the  injury.  3. 
Secondaiy  hcemorrhage  is  that  which  occurs  any  time  after  the 
first  twenty-four  hours,  and  is  due  to  the  failure  of  the  process  for 
the  permanent  closure  of  the  vessel.  The  treatment  in  each  case 
is  different. 

(i)  Primary  artkrlal  h/f.morrhage. — The  older  Surgeons 
resorted  to  very  barbarous  methods  of  controlling  haemorrhage, 
such  as  plunging  stumps  after  amputation  into  boiling  jMtch,  or 
operating  with  a  red-hot  knife,  and  it  was  not  till  Nature's  method 
of  arresting  bleeding  had  been  intimately  studied,  both  in  the 
human  subject  and  by  experiments  on  animals,  that  the  local 
treatment  of  haemorrhage  was  placed  upon  a  scientific  basis.  It 
may  be  best,  therefore,  first  to  consider  Nature's  method  of  con- 
trolling hcBmorrhage  before  describing  the  surgical  measures  which 
have  been  founded  upon  it.  When  an  artery  of  small  or  moder- 
ate size  is  comjjjetely  divided,  the  cut  end,  in  consequence  of  the 
injury  stimulating  the  muscular  fibres  in  the  middle  coat,  con- 
tracts, thus  lessening  the  size  of  the  orifice,  and,  in  the  case  of 
the  small  arteries,  com])letely  closing  it.     At  the  same  time,  the 


TREATMENT    OF    HEMORRHAGE. 


127 


cut  end,  owing  to  the  normal  elastic  tension  of  the  artery,  retracts 
within  its  sheath,  leaving  the  surface  of  the  latter  rough  and  uneven. 
The  diminution  in  the  size  of  the  orifice  retards  the  escape  of 
blood.  The  slower  current  passing  over  the  divided  wall  of  the 
artery,  and  the  roughened  internal  surface  of  the  sheath,  in  con- 
sequence of  this  multiplication  of  points  of  contact  and  exposure 
to  the  air,  coagulates,  gradually  blocks  up  the  orifice,  and  fills  the 
sheath  around  and  beyond  the  retracted  end  of  the  artery,  form- 
ing what  is  called  the  external  clot.  The  stream  having  been 
thus  slowed  or  stopped,  the  blood  inside  the  vessel  also  co- 
agulates, and  the  coagulation  spreading  from  the  clot  that  blocks 
up  the  orifice  to  the  first  collateral  branch,  forms  what  is  called 
the  internal  clot  (Fig.  29).  When  the  hemorrhage  has  been 
severe,  two  other  factors  favor  the  formation  of  these  clots,  viz., 
(i),  the  enfeeblement  of  the  heart's  action  induced 
by  the  tendency  to  syncope,  and  the  consequent 
diminished  force  with  which  the  blood  is  propelled 
from  the  divided  vessel;  and  (2)  the  increased  ten-  j' 
dency  of  the  blood  to  coagulate  owing  to  an  altera- 
tion in  its  composition  caused  by  the  absorption  of 
watery  fluid  from  the  tissues  to  make  up  for  the 
amount  of  blood  lost  by  the  hperaorrhage.  Thus  the 
haemorrhage  is  arrested,  and  still  presuming  that  the 
vessel  be  of  a  small  or  medium  size,  it  may  not  recur, 
and  Nature  will  permanently  close  the  wounded  ves- 
sel in  the  way  to  be  presently  described.  It  is  only, 
however,  when  the  vessel  is  small,  that  Nature  can 
be  thus  trusted.  When  a  large  vessel  is  wounded, 
she  is  quite  impotent  to  prevent  an  immediate  fatal 
issue ;  whilst  if  the  vessel  is  of  medium  size,  as  the 
syncope  passes  off,  and  the  heart  again  begins  to  act  with  vigor, 
the  clots  may  be  washed  away  and  the  bleeding  recur  till  fainting 
once  more  ensues.  In  this  way  bleedings,  alternating  with  tem- 
porary arrests,  exhaust  the  patient's  strength,  till  he  finally  suc- 
cumbs to  fatal  syncope. 

The  method  by  which  nature  permanently  closes  the  vessel  is 
as  follows  :  The  clot  between  the  artery  and  the  sheath  prevents 
the  artery  from  dilating  on  the  cessation  of  the  contraction  of  the 
muscular  fibres  of  the  middle  coat  \  whilst  the  internal  clot  acts, 
so  to  speak,  as  a  buffer,  and  thus  prevents  the  force  of  the  blood- 
stream being  exerted  to  its  full  on  the  end  of  the  vessel  while 
healing  is  taking  place.  The  injury  inflicted  on  the  coats  of  the 
vessel  by  its  division  sets  up  a  traumatic  inflammation.  Leucocytes 
and  serum  escape  from  the  vasa  vasorum  of  the  divided  vessel- 
walls  and  tissues  about  the  cut  end  of  the  vessel,  whilst  there  is 


Diagram  of  a 
wounded  ar- 
tery closed  by 
clots. 


128  GENERAL    PATHOLOGY    OF    INJURIES. 

proliferation  of  the  endothelial  and  connective  tissue  cells  from 
the  margin  of  the  torn  coats  of  the  vessel.  The  cells  thus  formed 
gradually  permeate  both  the  internal  and  external  clots  so  that 
the  end  of  the  artery  in  a  few  hours  becomes  surrounded  by  a 
small  mass  of  coagulable  lymph.  The  artery  at  the  same  time 
contracts  on  the  internal  clot,  which  gradually  loses  its  red  color 
as  it  is  invaded  by  the  inflammatory  exudation.  New  vessels 
grow  out  from  the  vasa  vasorum  of  the  arterial  wall,  and  from  the 
granulation  tissue  about  the  cut  end  of  the  vessel,  and  invade  the 
inflammatory  exudation,  which  has  now  replaced  the  internal  clot. 
Thus  the  internal  clot,  instead  of  as  at  first  being  merely  adherent 
by  its  base  to  the  end  of  the  divided  artery,  is  now  intimately 
blended  with  the  arterial  walls,  forming  a  plug  of  vascular  granu- 
lation tissue.  The  granulation  tissue  is  next  converted  into 
fibrous  tissue,  which  gradually  contracts  and  obliterates  the  newly- 
formed  vessels,  till  finally  the  internal  clot  together>vith  the  artery 
is  converted  as  far  as  the  first  collateral  branch  into  a  firm  fibrous 
cord.  Similar  changes,  in  the  meanwhile,  occur  in  the  external 
clot,  and  it  is  finally  blended  with  the  scar-tissue  formed  by  the 
healing  of  the  wound  of  the  soft  parts  around  the  injured  artery. 
When  an  artery  is  divided  in  its  continuity,  the  healing  of  the 
distal  end  is  accomplished  in  a  similar  manner,  except  that  the 
internal  clot  in  the  distal  end  is  often  less  perfectly  produced, 
and  may  not  be  formed  st  all.  Consequently,  secondary  haemor- 
rhage is  more  frequent  from  the  lower  than  from  the  upper  end 
of  a  ligatured  artery. 

The  above  description  applies  chiefly  to  a  complete  division  of 
an  artery.  When  an  artery  is  merely  punctured,  the  arrest  of 
haemorrhage  will  depend  upon  the  size  of  the  vessels,  and  the  size 
and  direction  of  the  puncture.  A  wound,  however  small,  of  the 
aorta,  or  vessel  next  removed  in  size,  will  probably  be  fatal.  In 
a  vessel  of  less  magnitude,  when  the  puncture  is  small,  a  clot 
'  forms  of  an  hour-glass  shape,  thus  blocking  up  the  wound,  and 
healing  occurs  by  adhesive  inflammation.  A  somewhat  larger 
wound,  when  made  longitudinally  to  the  artery,  may  heal  in  the 
same  way ;  but  when  made  transversely  to  the  axis  of  the  vessel, 
it  assumes  a  diamond  shape,  in  consequence  of  the  elastic  tension 
of  the  coats,  and  the  haemorrhage  will  probably  not  be  arrested. 
The  sur(;ical  mei  hods  of  arres'j  ing  HyicMORRHAGE  may  be  con- 
sidered under  the  heads  of  temporary  and  permanent  methods. 

I.  Tempo7'ary  methods. — The  surgeon,  if  the  bleeding  point  is 
within  reach,  need  never  fear  haemorrhage,  as  mere  pressure  with 
the  finger  will  control  it,  whatever  the  size  of  the  vessel,  till  he 
can  obtain  the  means  of  permanently  arresting  it.  The  pressure 
may  be  made  directly  on  the  bleeding  point,  or  between   the 


SURGICAL    METHODS    OF    ARRESTING    HEMORRHAGE. 


129 


wound  and   the   heart ;   in  the  former  situation  with  the  finger, 
Spencer  Wells'   pressure- forceps  (Fig.  30)  or  the  tourniquet;-  in 


Fig.  30. 


Spencer  Wells'  pressure-forceps,  modified  by  Morrant  Baker. 

the  latter  situation  with  the  finger  or  the  tourniquet,  the  pressure 
being  then  made  in  such  a  direction  as  to  press  the  artery  against 
some  resisting  structure,  as  a  point  of  bone.  The  tourniquets 
employed  are  various  (Fig.  31  and  Fig.  32).  The  rubber  tube 
of  the  Esmarch's  apparatus  perhaps  answers  the  best.  An  im- 
promptu tourniquet  may  be  made  by  tying  a  pocket-handkerchief 
loosely  round  the  limb,  and  twisting  it  up  tightly  with  a  walking- 


FlG.  31. 


Fig.  32. 


Signoroni's  Tourniquet. 


Petit's  Tourniquet. 

Stick  or  umbrella.  These  temporary  means,  however,  should 
only  be  trusted  to  until  more  permanent  methods  can  be  applied. 

2.  Permanent  methods. — The  agents  employed  for  permanently 
arresting  haemorrhage  are — i.  Cold,  2.  Heat,  3.  Pressure,  4. 
Styptics,  5.  Cautery,  6.  Ligature,  7.  Torsion,  8.  Acupressure, 
9.  Forcipressure. 

I.  Cold  is  only  applicable  to  stopping  hemorrhage  from  small 
vessels.  It  acts  by  causing  the  muscular  coat  to  contract,  thus 
promoting  the  coagulation  of  the  blood   in  the  arterioles  and ' 


130  GENERAL  PATHOLOGY  OF  INJURIES. 

capillaries.  It  is  frequently  employed  in  the  form  of  cold  water 
or  ice  to  arrest  bleeding  from  the  smaller  vessels  in  operation 
wounds,  and  is  a  well-known  domestic  remedy  for  checking 
epistaxis,  etc. 

2.  Heat  in  the  form  of  hot  water  is  now  often  employed  in 
place  of  cold  water  in  large  operation  wounds,  as  cold  applied  to 
a  large  surface  tends  to  increase  the  shock  of  the  operation. 
The  water  must  be  hot  (110°  to  120°)  ;  warm  water  merely  en- 
courages the  haemorrhage  by  washing  away  the  coagula  blocking 
the  vessels.  Heat,  like  cold,  acts  by  stimulating  the  muscular 
fibres  of  the  vessel  to  contract. 

3.  Pressure  as  a  temporary  means  of  arresting  haemorrhage  has 
already  been  mentioned.  Firmly  apphed  to  the  flaps  covering  a 
wound,  it  is  an  efficient  method  of  controlling  the  bleeding  from 
the  numerous  small  vessels  necessarily  divided  in  operations.  In 
the  form  of  a  plug  or  tampon  it  is  the  best  means  at  our  com- 
mand in  certain  situations  where  the  artery  cannot  be  secured  by 
more  reliable  methods,  as  the  rectum,  vagina,  tonsil,  nose,  socket 
of  a  tooth,  interior  of  bone,  etc.  It  is,  moreover,  frequently  em- 
ployed to  stop  haemorrhage  from  a  moderate-sized  artery  where 
such  can  be  pressed  against  a  bone,  as  in  the  scalp  ;  whilst  in  the 
form  of  a  graduated  compress  it  is  especially  applicable  to  wounds 
of  the  palmar  arch.  Pressure  acts  mechanically  by  closing  the 
vessel. 

4.  Styptics  arrest  haemorrhage  by  inducing  the  coagulation  of 
the  blood.  Those  most  in  use  are  perchloride  of  iron,  hamamelis, 
and  nitrate  of  silver.  Of  the  perchloride  of  iron,  the  strong  liquor 
and  the  solid  form  are  the  most  efficient  preparations.  Styptics 
may  be  most  usefully  employed  in  conjunction  with  pressure  in 
cases  where  the  latter  alone  has  proved  ineffectual.  The  objec- 
tion to  their  use  is  that  they  are  apt  to  cause  inflammation  and 
sloughing  of  the  tissues,  and  consequently  secondary  haemorrhage 
is  liable  to  occur  on  the  separation  of  the  slough.  A  few  years 
ago  a  case  came  under  the  care  of  a  colleague  in  which  two 
inches  of  the  median  nerve  were  destroyed  by  the  sloughing  fol- 
lowing the  application  of  perchloride  of  iron  to  a  wound  of  the 
brachial  artery.  Styptics  should  never  be  used  where  more  effi- 
cient and  safer  means  of  arresting  haemorrhage  can  be  adopted. 
A  new  styptic,  consisting  of  a  solution  of  fibrin  ferment  (i  to  10) 
to  which  calcium  chloride  1  p.  c.  has  been  added,  is  said  to  act 
only  on  the  blood,  not  on  the  tissues,  and  to  be  perfectly  aseptic. 
It  was  found  by  Mr.  Wright  to  be  effectual  in  arresting  haemor- 
rhage after  the  division  of  all  the  veins  except  the  common 
jugular  in  a  dog's  neck. 

5.  The  cautery  arrests  bleeding  in  part  by  causing  the  muscu- 


SURGICAL   METHODS    OF    ARRESTING    HEMORRHAGE.  I3I 

lar  coat  of  the  artery  to  contract,  in  part  by  inducing  coagulation 
of  the  blood,  and  in  part  by  charring  the  tissues  and  so  producing 
an  eschar  which  checks  or  prevents  the  flow  of  blood.  The 
wound  should  be  first  dried  by  pressure  with  lint,  and  then  imme- 
diately touched  lightly  with  the  cautery,  which  should  be  at  a  dull 
red  heat,  as,  if  used  hotter  than  this,  it  simply  destroys  the  tissues 
without  producing  the  above  effects,  and  the  htemorrhage  con- 
tinues. It  may  be  applied  in  the  form  of  the  cautery-iron,  which 
is  simply  heated  in  the  fire  ;  but  Paquelin's  benzoHne  cautery  and 
the  galvano-cautery  are  much  more  convenient.  The  chief  ob- 
jection to  the  use  of  the  cautery  is  that  it  causes  destruction  of 
the  tissues  around,  and  on  the  separation  of  the  resulting  eschar 
secondary  haemorrhage  is  liable  to  ensue.  The  cautery  should 
never  be  used  in  a  clean-cut  wound. 

6.  Ligature  is  the  most  reliable  method  of  permanently  arrest- 
ing hsemorrhage,  and  is  the  one  most  frequently  employed.  Silk, 
China-twist,  whipcord,  carbolized  and  chromicized  catgut,  kanga- 
roo-tail-tendon, and  ox-aorta  are  the  materials  chiefly  used  as 
ligatures.  Of  these  chromicized  catgut,  if  rendered  aseptic  in 
the  way  mentioned  at  page  94,  answers  admirably  for  securing  the 
cut  ends  of  arteries  in  amputation  and  other  wounds.  For  the 
ligature  of  arteries  in  their  continuity,  the  choice  of  ligature  is 
still  open  to  question,  and  will  be  referred  to  again  under  ligature 
of  arteries.  Whatever  form  of  ligature  is  used  it  should  not  be 
too  thick,  or  the  internal  and  middle  coats  will  be  unevenly 
divided  or  may  escape  division  altogether.  At  the  same  time  it 
should  be  strong  enough  to  resist  absorption  or  softening  till  the 
artery  is  securely  sealed.  It  should  be  tied  tightly  till  the  internal 
and  middle  coats  are  felt  to  yield,  but  not  so  tightly  as  to  cut 
through  the  external  coat.  Messrs.  Ballance  and  Edmunds,  as 
the  result  of  an  experimental  enquiry  on  the  Hgature  of  the  larger 
arteries  in  their  continuity,  have  advocated  that  two  ligatures 
should  be  applied  so  as  merely  to  occlude  the  lumen  of  the  vessel, 
without  dividing  the  internal  and  middle  coats.  These  observa- 
tions, however,  can  hardly  apply  to  the  ligature  of  the  cut  end  of 
arteries  in  wounds,  as  unless  the 
ligature  is  applied   tightly   to   such  F"=-  33- 

there  is,  obviously,  danger  of  its 
slipping.  An  artery  is  tied  in  an 
open  wound  by  seizing  the  cut  end  Artery  forceps. 

with  nibbed  forceps  (of  which  Fig. 

33  is  one  of  the  best  forms),  drawing  it  gently  from  its  sheath, 
throwing  a  ligature  round  it,  and  then  tying  the  ligature  in  a  reef- 
knot  (Fig.  34,  A).  Both  ends  of  the  ligature  are  then  cut  off 
short. 


132 


GENERAL   PATHOLOGY   OF   INJURIES. 


Effects  of  ligahire. — When  a  ligature  is  properly  applied  the 
internal  and  middle  coats  are  evenly  and  transversely  cut  through 
by  its  pressure.  Their  cut  edges  retract  and  curve  within  the 
canal  of  the  vessel,  and  the  external  coat,  crumpled  up  and 
tightly  embraced  by  the  hgature,  retains  the  two  inner  coats  in 


Fig.  34. 


A.     The  reef-knot  versus  B,  the  granny-knot. 


Diagram  of  a  liga- 
tured artery.  E. 
External;  M. 
Middle;  and  I. 
Internal  coat. 
L.  Ligature. 


contact  with  each  other  (Fig.  35).  A  clot  of  conical  shape  forms 
in  the  vessel,  extending  from  the  seat  of  ligature  to  the  first 
collateral  branch,  and  subsequently  becomes  adherent  by  its  base 
to  the  wall  of  the  vessel.  The  cut  ends  of  the  internal  and  middle 
coats  unite  by  adhesive  inflammation.  When  an  aseptic  ligature 
is  used,  and  the  wound  runs  an  aseptic  course,  the  ligature  be- 
comes embedded  in  the  granulation  tissue,  and,  if  of  animal 
material,  absorbed,  or  in  the  case  of  silk,  encysted.  The  per- 
manent closure  of  the  artery  is  accomplished  by  the  process 
already  described  under  Nature's  Method  of  controlling  hcemor- 
rhage  (p.  126). 

7.  Torsion  consists  in  seizing  the  artery  firmly  with  the  torsion- 
forceps  (Fig.  36),  drawing  it  gently  from  its  sheath,  and  twisting 

it  sharply  several  times  in  its 
long  axis  till  the  internal  and 
middle  coats  are  felt  to  yield. 
'I'he  process  resembles  the  tear- 
ing across  of  an  artery,  such  as 
occurs  in  the  avulsion  of  a  limb. 
When  torsion  is  successfully  jjcrformed,  the  internal  and  middle 
coats   are  ruptured    and    bent  upwards   into    the    lumen  of  the 


Fk;.  36. 


I'orsion-fortx-ps. 


.^===> 


RECURRENT   HEMORRHAGE.  133 

artery,  and  the  external  coat  is  twisted  up  into  a  cone  (Fig.  37). 

A  clot  then  forms,  and  the  artery  heals  permanently  in  the  way 

already  described.     It  appears  to  be 

a  rehable  method,  but  takes  a  longer  _     ^"^"  ^''" 

time  in  its  performance  than  ligature.     XrnnJr 

8.  Acupressure  consists  in  secur-     .  /'f  — | 
ing  the  end  of  the  bleeding  artery  ^' 
by  pressing  it  between  an  acupres-  I  MWkTwlstccl end 
sure    needle    (which    resembles    a  ^^^9  ^-^'^^'y' 
hare-hp   pin)    and    the   tissues,    or 
between    the    needle    and    a    wire 
twisted     over     the     needle.      This 

method    is    scarcely    ever    used     now.  Effect  of  torTion  on  an  artery. 

9.  FoRciPRESSURE  consists  in  seiz- 
ing the  bleeding  artery,  and  the  surrounding  tissues  if  the  vessel 
is  small,  with  Spencer  VVells'  pressure-forceps,  leaving  them  on  a 
few  minutes  and  then  very  gently  withdrawing  them.  It  is  a 
means  often  used  to  control  the  haemorrhage  during  an  operation, 
and  will  even  permanently  arrest  it  in  the  case  of  the  smaller 
vessels,  which  are  often  found  not  to  bleed  when  the  forceps  are 
removed.  It  is  sometimes  employed  for  arresting  hseraorrhage 
from  a  vessel  which  from  its  depth  or  other  cause  cannot  be  tied. 
In  such  a  case  the  forceps  are  left  on  from  twelve  to  twenty- four 
hours,  and  at  the  end  of  that  time  are  very  gently  removed  so 
as  not  to  re-start  the  bleednig. 

(2)  Recurrent,  reactionary,  or  intermediary  HiEMORRHAOE 
is  that  which  may  come  on  within  the  first  twenty-four  hours  after 
a  wound  as  the  patient  gets  warm  in  bed,  and  the  shock  of  the 
operation  or  injury  has  passed  off.  It  may  be  regarded  as  a  fail- 
ure in  the  process  of  the  temporary  closure  of  the  vessel.  It 
should  be  noted  that  the  term  recurrent  is  by  some  authors 
applied  to  what  is  here  called  secondary  haemorrhage.  Causes. — 
I.  Slipping  of  a  ligature  or  displacement  of  a  clot  from  a  vessel, 
consequent  upon  the  wounded  parts  not  being  kept  at  rest.  2. 
V/ashing  out  of  a  clot  from  a  vessel  which  it  has  temporarily 
plugged,  by  the  increased  force  of  the  circulation  as  the  heart  re- 
gains power  on  the  passing  off  of  the  syncope  or  shock.  It  is  not 
uncommon  in  large  wounds  to  have  some  oozing  of  blood  through 
the  dressings  ;  but  this  should  not  be  considered  as  recurrent 
haemorrhage  unless  it  occurs  in  unusual  quantities,  and  only  then 
calls  for  treatment.  The  soiled  dressings  having  been  covered 
with  fresh  layers  of  the  antiseptic  gauze  and  wool,  the  part  should 
be  firmly  but  gently  bandaged  and  then  elevated.  This  failing, 
the  dressings  must  be  removed,  and  the  flaps  in  the  case  of  an 
amputation  separated,  the  clots  washed  away  with  cold  or  hot 


134  GENERAL   PATHOLOGY   OF   INJURIES. 

water  containing  an  antiseptic,  and  any  vessel  found  bleeding, 
tied.  The  wound  should  be  then  re-dressed  and  firm  pressure 
applied. 

(3)  Secondary  hemorrhage  is  that  which  occurs  after  the 
period  of  reaction  has  passed  in  consequence  of  the  failure  of  the 
process  for  the  permanent  arrest  of  haemorrhage. 

Cause. — Secondary  haemorrhage  is  due  either  to  the  defective 
formation  of  the  internal  clot,  or  to  the  failure  of  union  of  the  in- 
ternal and  middle  coats.  Either  of  these,  again,  may  be  {a)  the 
result  of  some  fault  in  the  surgical  means  taken  to  arrest  the 
primary  hccmorrhage,  and  then  in  some  measure  may  be  said  to 
be  preventable  ;  or  {b)  the  result  of  some  disease  of  the  vessel  or 
constitutional  state  of  the  patient,  and  then  may  usually  be  re- 
garded as  non-preventable.  These  causes  may  be  considered 
under  the  following  heads  : — 

1.  Defect  in  tJie  ligature  or  in  its  application. —  {a)  An  improp- 
erly prepared  animal  ligature  may  become  absorbed  too  soon. 
{I))  A  non-absorbable  ligature,  if  chosen,  may  be  too  thick  or 
tape-like,  and  hence  not  divide  or  unevenly  divide  the  internal 
and  middle  coats.  (<r)  The  ligature  may  not  be  aseptic,  and  so 
cause  suppurative  instead  of  adhesive  inflammation,  {d)  The 
ligature,  whatever  kind  is  used,  may  be  tied  too  tightly  or  too 
loosely,  or  be  unevenly  knotted,  {e)  The  sheath  in  applying  the 
ligature  may  be  too  freely  separated  from  the  artery,  or  the  artery 
bruised  during  the  separation  of  the,sheath.  (/)  The  ligature 
may  be  placed  too  near  a  collateral  branch. 

2.  Defect  in  the  management  of  the  wound. — The  tissues  may 
be  roughly  handled  and  bruised,  or  the  wound  may  be  imperfectly 
drained  and  the  discharges  allowed  to  become  septic  or  infected 
by  pathogenic  organisms,  so  that,  in  either  case,  septic  inflamma- 
tion and  suppuration  may  be  set  up  and  spread  to  the  vessel  and 
its  contained  clot. 

3.  Disease  of  the  vessel-walls. — Under  this  head  maybe  men- 
tioned atheroma,  calcareous  degeneration,  and  syphilitic  and 
tubercular  disease,  aU  of  which  may  either  allow  the  ligature  to 
cut  its  way  too  quickly  through  the  diseased  coats,  or  prevent  the 
adhesion  of  the  internal  and  middle  coats  and  the  other  changes 
that  should  occur  in  the  normal  process  of  healing. 

4.  Constitutional  conditions. — These  are  such  as  render  the 
blood  less  coagulable  than  usual,  or  are  associated  with  an  in- 
crease of  the  blood-pressure  or  an  excited  action  of  the  heart. 
Amongst  such  conditions  may  be  mentioned  the  haemorrhagic 
diathesis,  diabetes,  Bright's  disease,  septicaemia,  pyaemia,  trau- 
matic fever,  and  plethora. 

Symptoms. — There  may  be  a  sudden  and  even  fatal  gush  of 


SECONDARY  HEMORRHAGE.  135 

blood,  or  previous  to  this,  the  discharges  of  the  wound  may  have 
been  blood-stained.  In  some  cases,  the  bleeding  may  stop  for  a 
time,  but  again  and  even  again  recur  till  the  patient  finally  sinks 
from  exhaustion.  Sometimes  the  haemorrhage  may  cease  spon- 
taneously after  one  or  more  bleedings,  and  the  patient  recover. 

Treatnent. — A.  From  an  artery  in  a  stump  after  operation. — 
The  treatment  will  differ  according  to  ( i )  the  date  at  which  the 
haemorrhage  occurs;  (2)  whether  it  is  from  the  main  artery  :  (3) 
the  condition  of  the  stump,  and  (4)  the  situation  of  the  amputa- 
tion. Thus,  when  the  haemorrhage  occurs  a  few  days  after  the 
operation,  and  is  little  more  than  a  mere  oozing,  elevation  and 
pressure  by  careful  bandaging  will  often  stop  it.  If  it  should  not 
do  so,  or  the  bleeding  is  more  severe  and  appears  to  come  from 
the  main  artery,  a  tourniquet  applied  to  the  artery  above  may 
succeed.  This  failing,  or  the  flaps  appearing  distended  with 
blood,  the  wound  should  be  opened  up,  the  clots  removed,  and 
the  bleeding  vessels  secured.  At  a  later  period,  when  the  healing 
process  has  considerably  progressed,  should  pressure  fail,  it  be- 
comes a  question  whether  the  healing  flaps  should  be  torn  apart 
and  the  artery  secured  at  its  bleeding  point,  whether  the  main 
artery  should  be  tied  above  the  wound,  or  whether  re-amputation 
should  be  performed.  If  the  main  artery  can  be  easily  secured 
just  above  the  operation  wound,  this  is  to  my  mind  the  proper 
procedure,  especially  if  the  wound  is  in  a  sloughy  condition,  in 
which  case  the  ligature  would  probably  not  hold  at  the  seat  of 
bleeding.  This  is  also  the  right  course  to  pursue  if  the  amputa- 
tion has  been  performed  at  the  shoulder  or  hip-joint ;  but  if  in 
the  lower  third  of  the  leg  or  in  the  fore-arm,  then  an  attempt 
should  be  made  to  tie  at  the  wound,  or  if  this  is  impossible  from 
the  sloughy  condition  of  the  stump,  re-amputation  is  probably 
the  safest  treatment. 

B.  From  an  artery  in  its  contimiity .—i^xfs&ViXt  should  first  be 
applied  at  the  seat  of  wound,  and  in  the  case  of  one  of  the  ex- 
tremities for  a  considerable  distance  over  the  course  of  the  artery, 
both  above  and  below  the  wound,  and  the  whole  hmb  bandaged 
from  the  foot  or  hand,  as  the  case  may  be,  upwards.  This  treat- 
ment failing  after  a  thorough  trial  of  it  has  been  made,  the  best 
plan,  as  a  rule,  is  to  cut  down  upon  and  tie  both  ends  of  the 
bleeding  artery  in  the  wound.  Tying  the  main  artery  at  a  dis- 
tance above  the  wound  has  been  advised,  but  is  open  to  the  objec- 
tion that  the  secondary  bleeding  often  comes  from  the  distal  end 
of  the  artery ;  and  that  even  when  it  comes  from  the  proximal 
end,  the  ligature  of  the  main  Vessel  may  not  control  it,  since 
blood  may  be  carried  into  the  artery  below  the  Hgature  by  collat- 
eral branches  (see  Fig.  57,  p.  200).     Further,  in  the  case  of  the 


136  GENERAL   PATHOLOGY    OF    INJURIES. 

lower  extremity,  there  is  also  a  danger  of  gangrene.  The  opera- 
tion of  tying  at  the  seat  of  wound  is  no  doubt  difficult,  as  the 
parts  are  generally  matted  together  or  in  a  sloughy  condition,  and 
the  coats  of  the  artery  so  softened  that  a  ligature  will  not  hold ; 
but  by  following  the  artery  a  little  way  upwards  and  downwards, 
a  healthy  portion  may  be  tound  whereon  to  place  the  ligature. 
The  steps  of  the  operation  are  greatly  facilitated  by  the  use  of 
Esmarch's  bandage.  When  the  hsemorrhage  comes  from  an 
artery  deeply  placed,  as  the  external  iliac  or  subclavian,  pressure 
is  probably  our  only  resource.  In  the  case  of  the  iliac,  an  at- 
tempt might  be  made  to  secure  it  at  the  bleeding  spot.  In  the 
only  instance,  however,  in  which  I  have  seen  it  tried,  it  was  un- 
successful. Should  haemorrhage  recur  after  both  ends  of  the 
artery  have  been  tied  at  the  seat  of  wound,  amputation  in  the 
case  of  the  lower  extremity  is  probably  the  safest  course. 

Venous  Haemorrhage. — When  a  vein  is  cut  completely  across, 
the  arrest  of  hsemorrhage  is  due  chiefly  to  the  formation  of  a 
coagulum  in  its  ulterior,  but  partly  to  the  collapse  of  the  vein. 
Treatment. — Unless  a  large  vein  is  wounded  in  its  continuity,  no 
treatment  beyond  pressure  is  usually  required.  Should  the  main 
vein  bleed  after  an  amputation,  a  ligature  should  be  applied  to  it. 
See  Treatment  of  wounded  veins. 

Capillary  hemorrhage  is  arrested  by  the  formation  of  coagula 
in  the  capillaries  and  smaller  arterioles.  The  coagulation  is  due 
in  part  to  the  exposure  of  the  blood  to  the  air ;  in  part  to  the 
traumatic  inflammation  set  up  in  the  capillary  wall  by  its  division  ; 
and  in  part  to  the  diminished  force  of  the  circulation  in  the  cap- 
illaries consequent  upon  the  reflex  contraction  or  even  closure  of 
the  arterioles  which  follows  the  division  of  the  tissues.  Treat- 
ment.— As  the  haemorrhage  usually  stops  spontaneously,  nothing 
in  the  way  of  treatment  is,  as  a  rule,  called  for.  Cold  or  hot 
water,  however,  may  be  used  to  more  (]uickly  cause  its  cessation  ; 
and  firm  pressure  on  bringing  the  wound  together  will  also 
check  it. 

CONSTITUTIONAL    EFFECTS    OF    INJURY. 

Shock  is  a  general  lowering  of  the  vital  powers  induced  by  a 
severe  impression  made  directly  on  the  nerve-centres,  or  indi- 
rectly through  the  perij^heral  nerves. 

The  causes  of  shock  may  be  divided  into  the  predisposing  and 
the  exciting.  Certain  conditions  prior  to  an  injury  or  an  opera- 
tion tend  to  make  the  shock  more  severe,  and  may  therefore  be 
regarded  as  predisposing  causes.  Such  are  Bright's  disease, 
hepatic  and  cardiac  mischief,  a  highly  nervous  and  hysterical 
temperament,  enfeebled  from  old  age,  sedentary  occupation,  ex- 


CONSTITUTIONAL    EFFECTS    OF    INJURY.  1 37 

cessive  fear  of  the  operation,  etc.  Among  the  exciting  causes 
.may  be  mentioned  mechanical  injuries,  especially  of  important 
parts  or  organs,  as  the  abdomen,  testicle,  etc.,  burns  and  scalds, 
especially  when  extensive  and  involving  the  trunk,  serious  opera- 
tions, particularly  when  prolonged,  undue  exposure  of  the  body 
to  cold  as  during  a  long  operation,  bites  of  venomous  reptiles,  the 
action  of  some  irritant  poisons,  the  sudden  emptying  of  an  over- 
distended  bladder,  etc.  Powerful  mental  emotions,  as  sudden 
fright,  giief,  or  joy,  are  sometimes  sufficient  of  themselves  to  pro- 
duce severe  and  even  fatal  shock.  In  fatal  cases  of  shock  from 
such  causes,  however,  some  visceral  disease  has  generally  been 
discovered.  Fright,  moreover,  adds  to  the  shock  produced  by 
mechanical  injury,  as  seen  for  example  in  railway  accidents, 
burns  from  the  clothes  taking  fire,  etc. 

Pathology. — But  little  is  found  post  inortem  in  fatal  cases  of 
shock.  The  right  side  of  the  heart  and  the  venous  system  gen- 
erally, especially  the  abdominal  veins,  may  be  engorged  with 
blood,  and  the  nerve-centres  anaemic.  Sometimes  the  heart  has 
been  found  empty,  and  if  the  shock  has  been  combined  with 
severe  haemorrhage  there  may  be  a  general  deficiency  of  blood  in 
the  body.  The  impression  produced  by  the  injury,  operation,  or 
mental  emotion  on  the  nervous  centres,  is  beheved  either — i,  to 
lead  to  paralysis  of  the  heart  directly  through  the  pneumogastric 
nerves;  or  2,  to  induce  through  the  splanchnics  a  vaso-motor 
paralysis  of  the  walls  of  the  abdominal  veins,  whereby  they  be- 
come engorged,  and  the  nerve-centres  and  heart  in  consequence 
imperfectly  supplied  with  blood  ;  hence,  partly  owing  to  deficient 
nervous  stimulus,  and  partly  to  lack  of  sufficient  arterial  blood  to 
the  heart's  substance  and  ganglia,  cardiac  paralysis  ensues. 

The  symptoms  vary  considerably  in  severity.  In  extreme 
cases  the  patient  lies  in  a  semi-conscious  state.  His  pulse  is 
feeble,  frequent  and  fluttering,  perhaps  hardly  perceptible  at  the 
wrist.  The  surface,  especially  that  of  the  extremities,  is  cold,  the 
temperature  falling  at  times  to  97°,  or  even  96°;  the  face  is  pale  ; 
the  lips  are  blanched  ;  the  skin  is  moist  or  covered  with  a  clammy 
sweat;  the  eye  is  half  closed,  and  lustreless  or  glazed;  and  the 
respiration  is  shallow,  and  may  be  barely  perceptible.  There  is 
marked  muscular  relaxation ;  there  may  be  yielding  of  the 
sphincters,  and  at  times  nausea  and  vomiting.  The  symptoms 
may  gradually  increase,  and  the  patient  die  of  syncope  or 
asthenia  ;  or  he  may  gradually  rally  or  pass  into  the  condition 
known  as  reaction.  The  pulse  will  then  become  full  and  increased 
in  frequency,  the  temperature  slightly  raised,  the  face  flushed,  the 
skin  hot  and  dry,  the  urine  scanty  and  high-colored,  the  tongue 
furred,  and  the  bowels  confined.  Many  of  the  feverish  symp- 
6* 


138  GENERAL    PATHOLOGY    OF    INJURIES. 

toms,  however,  that  were  formerly  regarded  as  the  result  of  ex- 
cessive reaction,  are  now  known  to  be  due  to  septic  poisoning. 

Treatment. — In  slight  cases,  beyond  covering  the  patient  up 
warmly  in  bed  with  blankets,  and  applying  hot  bottles  to  the 
feet,  nothing  is  required,  except  when  there  is  much  pain  a  sub- 
cutaneous injection  of  one-sixth  to  one  quarter  of  a  grain  of 
morphia.  In  severe  cases,  small  and  repeated  doses  of  brandy 
should  be  given,  carefully  watching  its  effect  upon  the  pulse  so  as 
not  to  subsequently  induce  excessive  reaction  ;  whilst  hot  bottles 
should  not  only  be  applied  to  the  feet,  but  placed  on  either  side 
of  the  thorax,  and  friction  used  to  the  hands  and  surface  gener- 
ally. If  there  has  been  severe  haemorrhage,  fluid  nourishment  in 
small  and  oft-repeated  doses  should  be  administered  with  the 
stimulant.  In  extreme  cases,  where  the  patient  is  unable  to 
swallow,  brandy  should  be  administered  by  the  rectum  or  ether 
injected  subcutaneously ;  whilst,  should  the  breathing  cease,  arti- 
ficial respiration  ought  to  be  employed  and  persevered  in  for 
some  time,  although  at  first  it  may  apparently  be  ineffectual. 
The  application  of  heat  by  means  of  hot  bottles  and  warm 
blankets  must,  in  the  meantime,  on  no  account  be  neglected. 
Hot  flannels  placed  over  the  cardiac  region  may  be  successful  in 
rousing  the  flagging  heart ;  and  in  the  case  of  a  child,  a  hot  bath 
may  be  given.  Should  the  jugular  veins  be  distended,  indicating 
an  over-full  and  partially-paralyzed  condition  of  the  right  side  of 
the  heart,  the  externa!  jugular  vein  may  be  opened.  On  the 
other  hand,  if  there  has  been  excessive  haemorrhage,  infusion  of 
saline  solution  should  be  performed,  the  extremities  in  the  mean- 
time being  raised  and  bandaged  so  as  to  impel  as  much  blood  as 
possible  to  the  nerve-centres  and  imperfectly-distended  heart. 
Electricity  in  some  cases  has  been  useful. 

Traumatic  fever. — After  every  injury,  when  severe,  the  tem- 
perature, even  when  there  is  no  wound,  as  in  some  cases  of  simple 
fracture,  may  rise  one  or  two  degrees,  but  falls  to  normal  about 
the  third  day,  whilst  the  tongue  may  become  slighdy  furred,  the 
bowels  confined,  the  appetite  lost,  and  the  pulse  increased  in 
frequency.  These  symptoms,  however,  pass  off  with  the  fall  of 
temperature,  and,  for  the  rest  of  the  period  while  the  wound  or 
injury  is  healintr,  the  patient's  general  functions  are  performed 
naturally.  This  condition  appears  to  depend  in  part  upon  an 
impression  made  through  the  peripheral  nerves  on  the  heat  regu- 
lating centre  in  the  medulla,  and  in  part  upon  the  absorption  of 
free  fibrin  ferment  which  escapes  with  the  leucocytes  and  serum 
in  the  process  of  the  simple  traumatic  inflammation  resulting  from 
the  injury.  This  simple  form  of  traumatic  fever  must  be  carefully 
distinguished  from  the  septic,  which  depends  on  the  absorption  of 


TRAUMATIC    FEVER.  139 

the  products  of  fermentation  or  putrefaction  from  a  septic  and 
imperfectly  drained  wound.  If  the  wound  is  allowed  to  become 
septic,  the  symptoms  of  simple  traumatic  fever  pass  into  those  of 
the  septic  form,  or  if  the  dose  of  poison  absorbed  has  been  large, 
into  those  of  saprEemia.  Simple  traumatic  fever  subsides  of  itself, 
and  requires  no  special  treatment  beyond  relieving  the  bowels  by 
a  gentle  purgative,  and  keeping  the  patient  on  slop  diet.  Septic 
traumatic  fever  will  be  described  under  septic  processes  in 
wounds. 

Traumatic  delirium  is  the  term  applied  to  the  delirious  state 
which  sometimes  supervenes  after  injuries  and  surgical  operations. 
The  delirium  may  depend  upon  several  distinct  conditions. 
Thus,  (i)  It  may  be  merely  a  symptom  of  septic  traumatic  fever, 
and  is  then  known  as  inflammatory  or  septic  traiunatic  delirium. 
(2)  It  may  occur  in  the  highly  nervous  or  neurotic  as  the  result 
of  severe  mental  strain  or  exhausting  brain-work  previous  to  the 
injury  or  operation,  being  then  spoken  of  as  nervous  traumatic 
delirium.  (3)  It  may  be  the  result  of  the  long-continued  abuse 
of  alcohol,  and  is  then  ordinary  delirium  tremens  brought  on  by 
the  accident  or  operation.  These  various  forms,  however,  no 
doubt  often  occur  together. 

Inflammatory  traumatic  delirium. — Of  this  variety  little  need 
be  said  further  than  that  it  generally  occurs  from  the  thirei  to  the 
fifth  day  when  the  septic  traumatic  fever  is  at  its  height,  and  that 
it  usually  begins  or  is  worse  in  the  night  and  abates  with  the  morn- 
ing remission  of  temperature.  The  treatment  is  that  of  septic 
traumatic  fever,  with  the  addition  of  an  ice-cap  to  the  head  when 
the  delirium  is  high. 

Nervous  traumatic  delirium,  though  rare,  sometimes  occurs  in 
subjects  of  a  susceptible  nervous  temperament  or  over-exhausted 
with  brain-work.  It  is  unaccompanied  by  fever  and  closely  re- 
sembles delirium  tremens,  except  that  it  is  not  due  to  alcoholism. 
The  delirium,  which  is  usually  of  a  low  and  muttering,  but  occa- 
sionally of  a  violent  or  maniacal  character,  usually  yields  to  quiet 
and  opium,  or  bromide  of  potassium  and  chloral,  with  careful 
feeding  and  the  judicious  employment  of  stimulants  where  such 
are  indicated. 

Alcoholic  traumatic  delirium  or  deliriu?n  tremens  differs  from 
the  inflammatory  variety  in  the  absence  of  fever,  and  in  the 
pecuhar  nature  of  the  delirium,  which  is  of  a  low  muttering  or 
busy  kind.  The  patient  has  delusions,  fancies  that  he  sees  ani- 
mals or  devils  under  his  bed  or  chair,  is  suspicious  of  his  friends, 
talks  constantly  to  himself,  answers  rationally  when  spoken  to,  but 
immediately  relapses  into  his  incoherent  muttering  state.  Some- 
times the  delirum  is  of  a  violent  character  ;  the  patient  will  not 


I40  GENERAL   PATHOLOGY    OF   INJURIES. 

remain  in  bed,  and  may  attempt  to  destroy  himself  or  those 
around  him.  The  temperature  is  normal  or  but  slightly  raised  ; 
the  skin  is  perspiring  •  the  hands  are  tremulous  ;  the  pulse  is  full, 
soft,  and  often  quickened ;  the  tongue  is  also  tremulous,  indented 
by  the  teeth,  and  coated  with  a  creamy  fur,  and  in  severe  cases 
becomes  dry  and  brown.  The  bowels  are  usually  confined.  The 
patient  cannot  sleep,  and  will  not  of  his  own  accord  take  food, 
but  will,  as  a  rule,  drink  anything. 

The  prognosis  is  good  when  the  patient  is  young,  and  can  be 
induced  to  take  food  ;  but  when  he  is  broken  down  in  health  or 
the  subject  of  visceral  disease  he  usually  sinks  into  a  state  of 
asthenia,  and  dies  of  exhaustion,  or  it  may  be  of  heart  failure  dur- 
ing a  paroxysm  of  violence. 

Treatment. — The  chief  indications  are  to  make  the  patient 
take  food  and  to  procure  sleep,  and  so  restore  power  to  the  ex- 
hausted nerve-centres.  Thus,  the  digestive  functions  should  be 
regulated  by  clearing  the  bowels  with  a  purgative  or  an  enema, 
and  by  the  subsequent  administration  of  tonics,  such  as  quinine. 
The  difficulty  in  getting  the  patient  to  take  food  may  generally  be 
overcome  by  a  judicious  mixture  of  firmness  and  coaxing,  other- 
wise he  must  fed  by  an  oesophageal  tube.  The  diet  should  con- 
sist of  fluid  nourishment  given  in  small  and  repeated  quantities  by 
night  as  well  as  by  day,  provided  the  patient  is  awake.  To  procure 
sleep  subcutaneous  injectious  of  morphia  (gr.  yi  to  J^),  or 
bromide  of  potassium  and  chloral  in  doses  of  twenty  grains  of  the 
former  to  fifteen  of  the  latter,  may  be  given  every  two  hours,  care- 
fully watching  their  effect.  Hyoscine  (gr.  -r^\-^  to  t-^^)  will  often 
cause  sleep  in  a  few  minutes.  Success  has  sometimes  been  ob- 
tained by  first  inducing  insensibility  by  chloroform,  and  following 
up  its  effects  by  the  subcutaneous  injection  of  morphia.  This 
plan  is,  however,  by  no  means  free  from  danger,  since  three 
deaths  occurred  at  St.  Bartholomew's  alone  in  seven  years.  If 
there  is  kidney  disease,  morphia  and  opium  should  not  be  given 
at  all,  or  with  great  caution.  The  question  of  administration  of 
stimulants  is  one  on  which  surgeons  differ.  Perhaps  the  best  rule 
is — where  the  patient  is  young  and  of  good  constitution,  to  with- 
hold them  entirely  ;  but  where  he  is  old,  broken  down  in  health, 
or  the  subject  of  visceral  disease,  to  give  them  in  moderate  quan- 
tities, regulating  the  dose  according  to  the  amount  of  depression 
and  the  effects  produced.  If  he  is  violent  or  noisy  he  must  be 
placed  in  an  isolation-ward,  and  prevented  from  injuring  himself 
or  his  attendants,  either  by  the  use  of  the  strait-jacket  or  by 
manual  restraint.  Seclusion  itself  has  often  a  good  effect  in  pro- 
ducing sleep.  The  management  of  a  local  injury  is  often  rendered 
very  difficult  by  the  patient  tearing  off  bandages,  splints,  etc.,  and 


DISEASES    DUE   TO    SEPTIC    PROCESSES.  I4I 

thus,  for  example,  converting  a  simple  fracture  into  a  compound 
one.  Such  mischief  can  only  be  prevented  by  the  greatest  watch- 
fulness and  care. 

DISEASES    THE    RESULT    OF    SEPTIC    AND    INFECTIVE    PROCESSES 
IN  WOUNDS. 

The  diseases  included  under  this  head  may  be  divided  into  two 
chief  classes,  the  septic  and  the  infective. 

The  SEPTIC  are  such  as  depend  upon  putrefaction  or  fermenta- 
tion, whereby  certain  chemical  products,  known  collectively  as 
ptomaines,  are  formed  and  set  up  local  inflammation,  and  if  ab- 
sorbed into  the  system  through  the  blood-  or  lymph-channels, 
give  rise  to  fever  or  other  constitutional  symptoms  known  as 
blood-poisoning.  These  chemical  products  are  believed  to  be 
of  the  nature  of  alkaloids,  and  to  act  on  the  tissues  locally,  or  on 
the  whole  system  if  absorbed,  as  intense  irritants,  and  in  a  man- 
ner similar  to  that  in  which  known  alkaloidal  bodies  do.  Thus,  they 
do  not  multiply  in  the  body,  and  the  effects  to  which  they  give 
rise  are  proportionate  to  the  dose  absorbed  ;  and  as  soon  as  the 
putrefactive  or  the  fermentative  processes  in  the  wound,  or  the  ab- 
sorption of  their  products,  are  prevented,  the  local  inflammation 
and  the  constitutional  symptoms  cease.  The  poison  is  non- 
infective  :  that  is,  if  an  animal  is  inoculated  with  the  blood  of  an- 
other suffering  from  a  septic  disease,  the  disease  is  not  trans- 
mitted. Neither  is  there  evidence  of  one  patient  being  able  to 
infect  another.  Micro-organisms  are  not  discovered  in  the  blood 
or  tissues  during  life,  nor  immediately  after  death. 

The  INFECTR^E  diseases,  on  the  other  hand,  depend  upon  inoc- 
ulation with  the  virus,  of  the  nature  of  micro-organisms,  or  of  an 
unorganized  ferment  produced  by  them  in  some  at  present  un- 
known way.  The  poison,  w-hatever  its  nature,  is  believed  to  thrive 
and  multiply  in  the  tissues  or  blood ;  the  effects  produced,  there- 
fore, are  not  proportionate  to  the  dose,  the  smallest  quantity 
introduced  into  the  system  being  sufficient  after  a  certain  incuba- 
tive period,  during  which  the  poison  is  multiplying,  to  set  up  local 
or  constitutional  effects.  The  infective  micro-organisms  may  be 
divided  into  two  chief  classes  :  ( i )  the  non-specific,  or  the  pyogenic 
bacteria,  which,  if  admitted  into  the  wound,  may  merely  set  up 
local  suppuration,  or  if  introduced  into  the  system  may,  under 
certain  conditions,  lead  to  disseminated  suppuration  through  the 
body  {Pycemia)  ;  and  (2)  the  specific  or  the  true  infective  micro- 
organisms, as  the  bacillus  of  anthrax,  which,  when  introduced  into 
the  tissue  or  system,  set  up  a  Hke  disease  to  that  from  which  the 
subject  they  were  taken  from  was  suffering.  Micro-organisms  in 
large  numbers  are  often  found  in  the  blood  and  in  the  tissues  im- 
mediately after  death. 


142  GENERAL   PATHOLOGY   OF    INJURIES. 

Both  septic  and  infective  diseases  may  occur  simultaneously  in 
the  same  subject.  Thus,  a  specific  virus  may  set  up  a  localized 
infective  inflammation  in  the  wound,  and  the  septic  products  of 
this  may  be  absorbed  into  the  system  either  with  or  without  the 
specific  virus.  Or  septic  products  in  the  wound  or  in  the  system 
at  large  may  favor  the  growth  and  development  of  the  infective 
organisms. 

These  diseases,  whether  septic  or  infective,  may  be  divided  into 
the  local  and  the  general :  that  is,  the  poison  may  set  up  local 
mischief,  which  may  or  may  not  be  followed  by  general  poisoning 
of  the  system  ;  or  the  whole  system  may  be  primarily  affected,  any 
local  mischief  that  may  occur  in  the  wound  being  merely  ot 
secondary  consequence. 

Classification  of  septic  and  infective  diseases  : — 

I.  Septic  DISEASES. —  (a)  Local. — i.  Septic  inflammation.  (/^) 
General. — i.  Septic  traumatic  fever;  2.  Saprsemia  or  septic 
intoxication;  and  3.  Hectic  fever. 

II.  Infective  diseases. —  (a)  Local. —  (i)  Non-specific.  i. 
Suppuration;  2.  Cellulitis;  3.  Hospital  gangrene;  4.  Wound- 
diphtheria.  (2)  Specific. —  I.  Cutaneous  erysipelas;  2.  Phleg- 
monous erysipelas ;  3.  Malignant  pustule ;  4.  Actinomycosis. 
{b)  General. — (i)  Non-specific. — i.  Pyaemia.  (2)  Specific. — 
I.  Septicaemia;  2.  Glanders;  3.  Hydrophobia;  4.  Tetanus; 
and  5.  Some  forms  of  Anthrax-poisoning. 

Septic  inflammation,  hectic  fever  and  spreading  traumatic  gan- 
grene have  already  been  described. 

General  Septic  Diseases. 

Septic  traumatic  fever  is  the  result  of  the  absorption  of  a 
moderate  dose  of  the  chemical  products  of  putrefaction  or  de- 
composition from  a  septic  or  imperfectly-drained  wound  (see 
septic  inflammation^.  It  begins  usually  about  the  second  or 
third  day  after  the  wound,  whether  this  be  the  result  of  injury  or 
of  operation,  with  a  feeling  of  chilliness  or  a  distinct  rigor.  The 
temperature  runs  u})  to  102°  or  103°  or  higher,  with  morning 
remissions,  the  pulse  is  increased  in  frequency,  the  skin  is  hot 
and  dry,  the  urine  is  scanty  and  high  colored,  the  tongue  is 
furred,  the  appetite  is  lost,  the  Ijowels  are  confined,  and  the 
patient  complains  of  headache  and  general  feeling  of  malaise, 
and  is  at  times  delirious.  The  symptoms,  which  are  generally 
at  their  height  about  the  sixth  or  seventh  day,  may  subside  as 
suppuration  is  estal)lished,  and  the  further  absorption  of  septic 
products  is  prevented  by  the  sealing  of  the  tissues  with  the  in- 
flammatory exudation  and   the  formation  of  granulation-tissue. 


SAPR^MIA   OR   SEPTIC   INTOXICATION.  1 43 

If  the  absorption  of  septic  products  continues  in  small  quantities 
the  fever  may  run  into  hectic,  or,  if  the  dose  of  poison  is  in- 
creased, into  saprasmia.  The  treatment  consists  in  at  once 
rendering  the  wound  aseptic  and  thoroughly  draining  it,  the 
bowels  in  the  meantime  being  opened  by  a  brisk  purge,  and  slop 
diet  continued. 

Sapr^emla.  or  septic  intoxication,  which  has  hitherto  been 
included  with  septic  infection  under  the  term  septicccmia,  is  a  form 
of  blood-poisoning  believed  to  be  due  to  the  absorption  in  large 
quantities  of  the  chemical  products  of  putrefaction  {sepsine, 
pittrescine,  cadaverine,  etc.),  derived  from  a  septic  or  ill-drained 
wound.  It  is,  therefore,  a  more  severe  form  of  septic  traumatic 
fever,  the  difference  being  one  of  degree  rather  than  of  kind. 
Clinically,  it  is  not  always  possible  to  distinguish  it  from  septic 
traumatic  fever  on  the  one  hand,  and  from  septicaemia,  or  even 
pyaemia  before  metastatic  abscesses  are  formed,  on  the  other 
hand.  It  is  probable,  moreover,  that  saprsemia,  septicaemia  and 
pyaemia,  though  each  may  depend  upon  a  different  poison,  often 
occur  simultaneously  in  the  same  subject. 

Cause. — For  sapraemia  to  occur  the  septic  poison  must  be 
absorbed  in  a  sufficient  quantity,  which  is  estimated  in  the  human 
subject  at  from  one  to  two  ounces.  Hence  the  cause  may  be 
said  to  be  those  conditions  that  lead  to  the  production  of  the 
poison  in  large  quantities  and  that  favor  its  absorption  into  the 
blood.  Amongst  these  maybe  mentioned — i.  Extensive  wounds 
recently  made,  inefficiently  drained,  and  not  kept  aseptic.  2. 
Wounds  of  serous  and  synovial  membranes.  3.  Abscesses,  cavi- 
ties, and  granulating  wounds  in  which  decomposing  discharges 
are  subjected  to  mechanical  tension  in  consequence  of  the  in- 
sufficiency of  the  external  opening. 

Pathology. — The  poison,  notwithstanding  its  virulence,  is  pro- 
ductive of  very  little  in  the  way  oi post-mortem  change  which  can 
be  said  to  be  characteristic.  The  parts  on  which  its  effects  are 
more  especially  manifested  are  the  blood,  the  gastro-intestinal 
canal,  the  nerve-centres,  and  the  kidneys.  Thus,  the  red  blood- 
corpuscles  undergo  rapid  disintegration,  causing  a  staining  of  the 
tissues  and  vessels,  and  are  found  aggregated  in  little  masses 
blocking  the  capillaries,  and  probably  in  consequence,  producing 
the  capillary  haemorrhages  {petechias)  which  are  found  more  or 
less  over  the  whole  body,  and  especially  beneath  the  serous  mem- 
branes. No  micro-organisms  are  found  in  the  blood.  The 
gastro-intestinal  canal,  the  nerve-centres,  and  the  viscera  gen- 
erally, are  congested  :  the  congestion  of  the  kidneys,  by  which 
organs  the  poison  is  principally  eliminated,  being  especially 
marked.     Decomposition  occurs  very  rapidly  after  death. 


144  GF.NEFL^L   PATHOLOGY    OF    INJURIES. 

The  Syynptoms,  of  which  headache,  vomiting,  and  delirium  are 
the  chief,  usually  come  on  about  the  second  day  after  the  inflic- 
tion of  the  wound,  and  may  be  ushered  in  by  a  slight  chill  or 
even  a  severe  rigor.  The  temperature  suddenly  rises  to  103°  or 
104°;  the  skin  becomes  clammy;  the  tongue  dry  and  furred; 
nausea  or  vomiting,  and  sometimes  diarrhoea  set  in  ;  the  patient 
becomes  delirious,  and  if  the  dose  of  the  poison  has  been  large 
or  its  continuous  absorption  is  not  prevented,  rapidly  sinks  into  a 
staie  of  collapse ;  the  temperature  falls  possibly  below  normal 
w^hilst  the  pulse  continues  rapid.  The  patient  becomes  uncon- 
scious, then  comatose,  and  then  dies.  Where  the  dose  absorbed 
has  been  less,  the  progress  of  the  disease  is  less  rapid,  the  patient 
becomes  angemic,  and  perhaps  jaundiced,  the  urine  albuminous, 
the  spleen  enlarged,  the  vomiting,  and  diarrhoea  continue,  and 
death  may  occur  from  exhaustion. 

The  Treatment  must  be  directed  to  the  removal  of  the  decom- 
posing discharges  from  the  wound  or  cavity.  If  this  is  promptly 
and  effectually  done,  the  disease  will  generally  be  arrested.  Thus, 
wounds  must  be  washed  out  with  antiseptic  lotions,  serous  cavities 
drained,  joints  laid  freely  open,  and  tension  in  abscesses  removed 
by  giving  free  vent  to  the  pent-up  and  decomposing  pus.  The 
patient's  strength  in  the  meanwhile  must  be  supported  by  fluid 
nourishment  and  the  judicious  administration  of  stimulants,  and 
the  subsequent  anaemia  combated  by  iron  and  quinine. 

Local  Infective  Diseases. 

Erysipelas  is  an  infective,  diffusely  spreading  inflammation, 
commonly  affecting  the  skin  or  subcutaneous  tissue,  or  both,  less 
frequently  the  mucous  membranes  or  submucous  tissue,  and  still 
more  rarely  the  serous  membranes  and  the  connective  tissue  in 
such  situations  as  the  pelvis,  orbit,  etc. 

Cause. — Erysipelas  depends  upon  the  introduction  "of  an  in- 
fective poison  into  the  system  ;  but  for  this  to  act  it  appears  nec- 
essary that  the  vitality  of  the  body  should  be  lowered,  and  the 
tissues  in  consequence  rendered  less  able  to  resist  the  injurious 
influence  of  the  poison.  The  causes,  therefore,  may  be  divided 
into  the  predisposing  and  the  exciting,  the  predisposing  again 
into  those  that  are  general  and  those  that  are  local. 

The  general precUspflsin^  causes  are  such  as  pertain  either  to  («) 
the  state  of  nutrition  of  the  body,  or  (/;)  its  environment,  {a) 
Among  the  conditions  that  predispose  to  the  disease  by  inducing 
an  impaired  state  of  the  tissues  are — i,  chronic  alcoholism  ;  2, 
Bright's  disease;  3,  diabetes  ;  4,  gout ;  5,  malignant  disease;  6, 
insufficient  food  ;   7,  want  of  exercise  combined  with  high  living; 


ERYSIPELAS.  1 45 

8,  previous  attacks  of  the  disease.  {^)  Among  the  causes  that 
pertain  to  the  environment  of  the  body  are  bad  hygienic  condi- 
tions of  all  kinds,  as — i,  imperfect  ventilation;  2,  defective 
drains ;  3,  accumulation  of  the  products  of  decomposing  organic 
matter;  4, overcrowding  ;  5,  want  of  cleanliness  ;  6,  a  large  num- 
ber of  suppurating  wounds  in  a  hospital,  and  7,  probably  certain 
not  altogether  understood  atmospheric  influences.  T/ie  local  pre- 
disposing cause  is  the  presence  of  a  wound,  scratch,  or  abrasion  of 
the  surface,  and  especially  of  a  lacerated  wound,  or  one  in  which 
the  discharge  is  undergoing  putrefaction. 

The  exciting  cause  is  the  introduction  of  some  infective  poison 
into  the  system.  This  poison  is  probably  not  the  same  in  each 
form  of  the  disease.  In  the  cutaneous  form  it  would  appear  from 
the  observations  of  Fehleisen  to  be  a  species  of  micrococcus,  the 
streptococcus  erysipelatosus,  Fig.  38. 
It  had  been  known  for  some  time  Fig.  38. 

that  micrococci  existed  in  the 
spreading  margin  of  cutaneous  ery- 
sipelas. Fehleisen  cultivated  some 
micrococci  from  this  source,  in  some 
instances  through  thirty  generations, 
/.  e.,  for  upwards  of  six  months,  and 
then  inoculated  several  patients,  in 
all  of  whom,  with  the  exception  of 
one,  who  had  just  recovered  from  an 
attack  of  the  disease,  erysipelas, 
after  an  incubation  period  of  from 
It;  to  60  hours,  was  set  up.*     The      ^.     c.  t.     •    , 

^  .  .  11,  '■"^    btreptococcus   Krysipelatosus 

contagion  may  be  conveyed  by  the  (Fehleisen). 

hands  of  the  surgeon  or  nurse,  and 

by  instruments,  sponges,  etc.,  and  probably  by  air  and  water.  It 
is  now  supposed  to  enter  the  system  in  all  cases  through  a  wound. 
The  so-called  idiopathic  erysipelas,  in  which  there  is  ostensibly  no 
wound,  was  thought  to  be  an  exception,  but  as  this  invariably  oc- 
curs on  exposed  parts,  as  the  face,  it  is  now  beUeved  that  the 
poison  gains  access  through  some  shght  crack  or  abrasion  that 
has  been  overlooked.  The  so-called  cellulo -cutaneous  and  cellu- 
lar varieties  have  not  been  proved  to  be  inoculable,  and  it  is  gen- 
erally held  that  they  depend  not  upon  a  specific  microbe,  but 
upon  the  ordinary  streptococcus  of  spreading  suppuration.  In 
that,  however,  they  bear  certain  clinical  resemblances  to  true  or 
cutaneous  erysipelas,  they  are  for  the  present,  in  accordance  with 
the  more  general  custom,  described  here  with  that  affection. 

*  These  inoculations  were  undertaken  for  the  cure  of  lupus  and  malignant 
tumors,  and  in  two  instances  apparently  with  success. 

7 


146  GENERAL    PATHOLOGY    OF    INJURIES. 

Pathology. — The  vims  when  inoculated  multiplies  in  the  tissues, 
and  spreads  by  the  lymphatic  vessels  and  spaces.  In  the  cutaneous 
form,  according  to  Fehleisen  and  Metchnikotf,  just  beyond  the 
spreading  edge  of  redness  where  the  skin  is  apparently  normal  the 
lymphatics  are  crowded  with  micrococci ;  beneath  the  inflamma- 
tory blush  the  vessels  are  dilated  and  the  tissues  softened  and  in- 
filtrated with  leucocytes  which  are  devouring  the  micrococci. 
Still  further  inwards  are  large  amoeboid  cells,  derived  from  the 
connective  tissue,  absorbing  the  leucocytes  and  their  contained 
micrococci,  whilst  beneath  the  part  where  the  blush  of  redness 
has  faded  only  dead  micrococci  are  seen.  The  septic  products 
of  the  micrococci,  after  passing  through  the  lymphatic  glands, 
which  become  swollen  and  tender,  enter  the  system,  producing 
the  constitutional  symptoms.  When  the  cellular  tissue  is  involved, 
suppuration  generally  occurs,  and  the  vessels  that  run  through  it 
to  the  skin  are  destroyed,  and  the  skin  in  consequence  sloughs. 
'\\\t  post-mortem  appearance  of  the  body  is  similar  to  that  seen  in 
other  cases  of  septic  poisoning.  The  organs  are  congested,  and 
the  blood  is  thin  and  fluid.  The  streptococci  are  not,  as  a  rule, 
found  in  the  blood ;  but  the  white  corpuscles  have  been  observed 
degenerated,  and  in  some  instances  forming  granular  masses, 
plugging  the  capillaries  of  the  lungs  and  brain. 

Varieties. — Erysipelas  may  be  divided  into — i,  the  cutaneous 
or  simple;  2,  the  cellulo  cutaneous  or  phlegmonous;  and  3,  the 
cellular  or  diffuse  cellulitis. 

T.  Cutaneous  or  simple  erysipelas  generally  attacks  the  skin, 
less  commonly  the  mucous  membrane.  It  is  a  specific  infective 
disease.     The  symptoms  are  local  and  constitutional. 

Local  signs. — There  is  a  vivid  flush  of  redness,  usually,  but  not 
invariably,  starting  from  a  wound,  and  appearing  either  simul- 
taneously with,  or  in  some  instances  not  till  twenty-four  or  forty- 
eight  hours  after  the  onset  of  the  constitutional  symi^toms.  The 
blush  has  a  great  tendency  to  spread,  or  to  suddenly  leave  one 
part  and  attack  another  {metastasis).  The  spreading  edge  is 
sharply  defined  and  slightly  raised  above  the  surroimding  skin, 
whilst  the  subsiding  edge  fades  off  into  the  healthy  skin.  The 
surface  is  usually  at  first  vividly  and  uniformly  red,  oedematous, 
and  shining,  the  redness  fading  momentarily  on  pressure,  and 
later  becoming  of  a  dusky  hue.  The  patient  complains  of  a  stiff- 
ness and  stinging  heat  in  the  ])art.  In  very  acute  cases  the  cuticle 
is  raised  into  blebs  by  the  exudation  of  serous  fluid  beneath  it,  and 
the  nearest  lymphatic  glands  are  generally  tender  and  enlarged. 
Where  the  tissues  are  lax,  as  about  the  face  or  scrotum,  there  is 
much  oedema,  but  there  is  little  tendency  to  suppuration.  When 
the  inflammation  subsifles,  there  is  usually  some  desquamation  of 
the  cuticle. 


CUTANEOUS   OR   SIMPLE    ERYSIPELAS.  I47 

The  wound  itself,  if  one  is  present,  takes  on  an  unhealthy  ap- 
pearance ;  it  ceases  to  heal,  the  edges  swell,  the  granulations 
shrivel,  and  the  surface  becomes  dry. 

The  constitutional sympioms  generally  begin  with  a  chill  or  rigor. 
The  temperature  suddenly  rises  to  103"  or  104°,  or  higher,  but  it 
does  not  fluctuate  as  in  septicaemia  and  pyaemia.  The  pulse  be- 
comes rapid,  and  there  is  headache,  loss  of  appetite,  furred  tongue 
and  constipation,  or  sometimes  diarrhoea. 

Termi7iations. — The  erysipelas  as  a  rule  gradually  subsides,  and 
the  patient  recovers  ;  or  it  may  spread  over  a  large  area,  and  the 
patient  sink  into  a  low  typhoid  state,  and  die  of  blood-poisoning, 
especially  when  the  subject  of  kidney  disease  or  other  visceral 
trouble.  When  about  the  head  and  face  it  may  spread  to  the 
larynx,  and  end  fatally  from  oedematous  laryngitis ;  or  it  may 
attack  the  membranes  of  the  brain  and  set  up  meningitis.  Re- 
lapses are  common. 

Treatment. — The  bowels  should  be  opened  by  a  smart  purge 
(Calomel,  gr.  v.  c.  jalap,  gr.  viii.),  and  subsequendy  perchloride 
of  iron  given  in  large  doses  (Tinct :  ferri  perchlor :  m.  xl,  quartis 
horis).  Slop  diet  is  usually  required  at  first,  but  as  the  constitu- 
tional symptoms  generally  assume  a  low  type,  the  patient  should 
not  be  too  much  depressed,  as  a  stimulating  plan  of  treatment  will 
probably  sooner  or  later  be  indicated.  Thus,  ammonia  and  bark, 
brandy-and-egg  mixture,  brandy,  strong  beef-tea,  etc.,  are  called 
for  should  the  temperature  run  high,  the  pulse  become  soft,  and 
the  tongue  dry  and  brown,  or  low  muttering  delirium  set  in. 
Locally,  nothing  answers  better  than  dusting  the  part  with  equal 
quantities  of  oxide  of  zinc  and  starch  powder,  and  enclosing  it  in 
a  thick  layer  of  cotton-wool.  When  there  is  an  unhealthy  wound, 
means  should  be  taken  to  render  this  aseptic ;  but  strong  anti- 
septics, as  carbolic  acid,  must  be  avoided,  as  they  cause  too  much 
irritation.  Should  there  be  any  collection  of  pus,  or  other  pent-up 
discharge,  it  must  of  course  be  let  out,  and  the  part  efficiently 
drained.  When  a  patient  is  attacked  with  erysipelas  in  an  hos- 
pital, he  should  be  removed  to  an  isolation  ward,  and  the  greatest 
care  taken  not  to  infect  other  patients.  It  was  an  old  practice  to 
draw  a  stick  of  nitrate  of  silver  over  the  skin  in  front  of  the 
spreading  edge  of  redness,  and  it  was  said  that  the  erysipelas 
would  not  pass  over  this  line.  Since  the  teaching  has  been  in 
vogue  that  the  inflammatory  reaction  follows  the  spread  of  the 
micrococci,  and  is  salutary  in  that  the  leucocytes  destroy  the 
micro-organisms,  attempts  have  been  made  to  set  up  inflamma- 
tion in  front  of  the  encroaching  microphytes  by  painting  the  skin 
with  tincture  of  iodine.  Cases  in  which  the  disease  is  said  to 
have  been  thus  arrested  have  been  reported. 


148  GENERAL   PATHOLOGY    OF   INJURIES* 

2.  Cellulo-cutaneous,  or  phlegmonous  erysipelas,  differs 
from  the  preceding  variety,  in  that  it  involves  the  subcutaneous 
tissue  as  well  as  the  skin.  It  has  not  been  proved  to  be  inocul- 
able,  and  is  generally  believed  to  depend  upon  a  poison  different 
to  that  setting  up  the  cutaneous  form,  most  likely  the  ordinary 
streptococcus  of  spreading  suppuration.  It  is  probably  always 
associated  with  a  scratch  or  v/ound,  and  nearly  always  terminates 
in  suppuration  of  the  subcutaneous  tissue  and  sloughing  of  the 
skin  ;  but  it  seldom  penetrates  beyond  the  deep  fascia,  unless  this 
has  been  injured.  It  is  most  common  in  the  intemperate,  or  those 
of  broken-down  constitution  or  the  subject  of  visceral  disease,  and 
is  especially  frequent  after  a  scalp  wound. 

Symptoms. — There  is  locally  much  more  oedema  and  swelling 
than  in  the  former  variety,  but  the  redness  is  less  bright  and  not 
so  sharply  defined,  and  blebs  or  bullae  containing  serum,  which 
may  be  blood-stained,  often  form  over  the  affected  part.  The 
pain,  at  first  hot  and  tingling,  soon  becomes  throbbing,  and  the 
swelling  brawny,  and,  should  suppuration  occur,  boggy  in  places; 
whilst  the  redness  assumes  first  a  dusky,  then  a  purple,  and  then 
a  mottled  hue  ;  finally,  dark-colored  sloughs  form,  but  no  point- 
ing occurs.  If  an  incision  is  made  into  the  tissues,  they  are  at 
first  found  infiltrated  with  fluid,  and  later  look  like  wet  wash- 
leather  from  the  breaking  down  of  the  cellular  tissue  into  pus  and 
sloughs.  As  the  inflammation  is  more  intense  than  in  cutaneous 
erysipelas,  so  are  the  constitutional  symptoms,  though  similar, 
more  severe.  The  fever,  at  first  slight,  assumes  a  typhoid  char- 
acter as  suppuration  sets  in.  The  disease  may  terminate  in  reso- 
lution, but  more  frequently  runs  the  course  above  described,  and 
may  end  fatally  from  broncho-pneumonia,  sapr?emia,  septicaemia, 
pyfemia,  exhaustion,  or  hectic.  It  is  most  fatal  when  as  is  so 
frequently  the  case,  the  patient  is  the  subject  of  chronic  kidney 
disease.  Locally  it  may  lead  to  necrosis  of  bone,  destruction  of 
a  joint,  brawny  thickening  of  the  part,  or  much  scarring. 

T7-eaimcnt. — This  must  be  both  constitutional  and  local.  A 
purgative  should  be  given  at  the  onset,  and  the  patient  placed  on 
slop-diet,  which  should  be  exchanged,  when  suppuration  occurs, 
for  concentrated  nourishment  with  bark,  iron,  and  stimulants. 
Locally,  lint  or  spongiopiline  soaked  in  hot  boracic  lotion  should 
be  applied,  and  incisions  made  early  before  sloughing  has  had 
time  to  take  place,  /.  c,  as  soon  as  the  parts  becoir.e  brawny.  A 
number  of  small  incisions  made  parallel  to  the  long  axis  of  the 
limb  arc  preferable  to  one  long  one.  They  should  extend  through 
the  skin  into  the  inflamed  cellular  tissue,  the  haemorrhage,  which 
is  often  free,  being  readily  stopped  if  excessive  by  plugging  with 
iodoform   or  sal  alembroth   gauze,  or  like   antiseptic    material. 


HOSPITAL    GANGRENE   OR    SLOUGHING   PHAGED.CNA.  149 

Subsequently  the  wounds  should  be  dressed  antiseptically,  well 
drained,  and  the  sloughs  removed  from  time  to  time  as  they  form. 
At  St.  Bartholomew's  Hospital  a  large  charcoal  poultice  is  \vith 
some  a  favorite  form  of  dressing.  Should  diarrhoea  set  in  it  may 
be  controlled  by  opium ;  but  this  drug  must  be  given  cautiously 
when  there  is  kidney  mischief.  In  bad  cases,  where  much  skin 
has  been  destroyed  or  a  joint  irreparably  damaged,  amputation 
may  ultimately  be  required,  but  should  not,  as  a  rule,  be  done 
whilst  the  disease  is  in  progress. 

3.  Cellular  Erysipelas,  or  diffuse  cellulitis,  is  an  acute, 
infective  and  diffuse  inflammation  of  the  cellular  tissue.  It  may 
occur  in  the  subcutaneous  or  submucous  tissues,  in  the  intermus- 
cular planes,  in  the  cellular  tissue  of  the  pelvis  or  orbit,  in  fact 
anywhere  in  the  body  where  connective  tissue  exists.  It  is  prob- 
able that  it  does  not  depend  upon  a  specific  virus,  but  upon  the 
streptococcus  of  spreading  suppuration,  and  hence,  although  it 
spreads  by  the  lymphatics  and  lymph-spaces  like  cutaneous  ery- 
sipelas, it  is  not  like  it  a  specific  infective  disease.  It  may  be  due 
to  various  causes.  Thus  it  may  occur  in  the  subcutaneous  tissue 
after  a  scratch  or  puncture,  particularly  one  infliicted  in  the  post- 
moi'tem  room,  or  by  the  bite  of  a  venomous  reptile  or  sting  of  an 
insect;  in  the  pelvic  cellular  tissue  after  parturition  or  the  opera- 
tion of  lithotomy  ;  and  in  the  submucous  tissue  after  an  injury,  as 
the  sting  of  the  throat  by  a  wasp. 

Symptoms.  —  The  constitutional  symptoms  resemble  those 
already  given  under  the  preceding  varieties  of  erysipelas,  and 
though  they  may  vary  in  intensity  they  are  generally  grave  and 
soon  assume  an  asthenic  type,  and  become  those  of  saprsemia  as 
the  septic  products  are  absorbed  from  the  decomposing  sloughs. 
The  local  symptoms  vary  according  to  the  part  attacked.  When 
the  subcutaneous  tissue  is  affected  they  are  similar  to  tho^e  of 
cellulo-cutaneous  erysipelas,  save  that  the  skin  is  not  at  first  in- 
volved, but  is  only  slightly  reddened  or  mottled ;  the  parts,  how- 
ever, feel  hard  and  brawn}',  and  become  boggy  as  suppuration 
occurs.  Later,  the  skin,  as  the  vessels  which  supply  it  are  de- 
stroyed by  the  pressure  of  the  inflammatory  exudation  in  the  sub- 
cutaneous tissue,  loses  its  vitality  and  rapidly  becomes  gangrenous 
and  sloughs. 

The  Tfeatmcnt  is  like  that  of  cellulo-cutaneous  erysipelas. 
Incisions  should  be  made  early,  and  stimulating  treatment  is  gen- 
erally required  from  the  first. 

Hospital  Gangrene  or  Sloughing  Phagedena  is  a  rapidly 
spreading,  infective  inflammation  accompanied  by  extensive 
sloughing  and  ulceration.  It  most  commonly  affects  an  open 
wound,  but  has  been  known  to  follow  injuries  where  there  has 


150  GENERAL   PATHOLOGY    OF   IN7URIES. 

been  no  break  in  the  skin.  It  is  seldom  seen  at  the  present  day 
owing  to  improved  hygiene,  better  hospital  management,  and  the 
more  scientific  treatment  of  wounds.  The  virus,  probably  the 
pvogenic  micrococci,  may  be  conveyed  to  the  wound  by  the  air, 
the  hands  of  the  surgeon  or  nurse,  instruments,  sponges,  etc. 
The  micrococci  iystreptococci  and  staphylococci)  are  found  in  chains 
and  masses  as  well  as  singly,  both  in  the  slough  and  in  the  in- 
flamed tissues  around.     (See  also  Phagedcenic  Ulcers,  p.  48.) 

SvJHpfofiis. — When  an  open  wound  is  attacked  a  pultaceous, 
ash-gray,  adherent  slough  forms  on  the  surface,  and  the  sloughing 
rapidly  spreads  both  deeply  and  widely.  The  edges  of  the  wound 
are  dusky-red,  oedematous,  sharp  cut,  and  rapidly  melt  away  as 
the  gangrene  proceeds.  The  discharge  is  thin  and  greenish  or 
blood-stained,  and  exhales  a  hoirible  foetor.  Although  a  local 
infective  disease,  severe  constitutional  symptoms  of  blood-poison- 
ing, rapidly  assuming  a  typhoid  character,  are  set  up  by  the  ab- 
sorption of  the  septic  products  (ptomaines),  and  frequently  ter- 
minate fatally  in  a  few  hours.  No  micro-organisms  have  been 
found  in  the  blood. 

Treatment — The  patient  should  be  isolated,  and  where  the 
disease  occurs  in  military  practice  as  an  epidemic,  the  whole  of 
the  patients  in  the  infected  building  should  be  removed  to  huts 
or  tents.  Stimulants,  opium,  and  quinine  should  be  given  inter- 
nally;  whilst  locally,  the  slough  must  be  completely  removed,  the 
ulcerated  surface  thoroughly  destroyed  by  strong  nitric  acid  or 
chloride  of  zinc,  and  the  wound  sprinkled  with  iodoform  and 
dressed  antiseptically. 

Wound-Diphtheria  is  rare  in  this  country.  It  is  thought  by 
some  to  be  a  mild -form  of  hospital  gangrene  due  to  the  ordinary 
microbes  of  suppuration,  by  others  to  be  a  distinct  affection  de- 
pending upon  a  specific  form  of  micrococcus,  and  the  result  of 
bad  hygiene  and  want  of  cleanliness  in  the  treatment  of  the 
wound.  When  a  wound  is  so  attacked,  the  surface,  previously 
granulating,  becomes  covered  with  a  grayish  white,  opaque,  ten- 
acious membrane,  similar  to  that  of  diphtheria.  This  membrane 
consists  of  granulation  cells  and  coagulated  exudation  in  which 
are  found  micrococci  in  chains  and  colonies.  The  affection  ap- 
pears to  be  only  very  slightly  contagious,  and  does  not  affect  the 
system  generally  further  than  by  the  absorption  of  the  septic  ])ro- 
ducts.  The  treatment  consists  in  attention  to  the  general  hygiene, 
and  dusting  the  wound  with  iodoform  or  rubbing  it  over  with  a 
stick  of  nitrate  of  silver. 

Malignant  Pustule  ok  Chakhon  is  a  specific  infective  disease 
due  to  inoculation  with  a  virus  {/mci//i/s  anthracis)  obtained  from 
animals  suffering  from  s])Icnic  fever.     It  occurs  most  frequently 


MALIGNANT    PUSTULE    OR    CHARBON.  151 

in  this  country  amongst  those  whose  work  brings  them  into  con- 
tact with  hifles  imported  from  countries  in  which  splenic  fever  is 
common.  The  bacilhis  may  enter  the  system  through  a  wound  or 
abrasion  of  the  skin,  a  pustule  occurring  at  the  point  of  inocula- 
tion. The  disease  may  then  remain  localized,  or  the  bacillus  may 
enter  the  blood  and  there  rapidly  multiplying  give  rise  to  consti- 
tutional symptoms.  At  times  the  bacillus  is  absorbed  directly 
into  the  blood  through  the  alimentary  or  respiratory  mucous 
membrane  without  any  external  manifestation,  and  sets  up  similar 
constitutional  symptoms,  the  affection  being  then  kno\vn  as  Wool- 
sorier's  Disease.     (See  a  work  on  Medicine.) 

Syviptoms. — A  red  itching  pimple  is  first  noticed,  generally  at 
the  situation  of  a  slight  scratch  or  abrasion  of  the  skin,  on  the  face 


I  'll'.lllV 


\    I"'/ 


Malignant  Pustule.     From  a  case  under  the  care  of  Mr.  Morrant  Baker. 

or  some  other  exposed  part.  The  pimple  soon  becomes  con- 
verted into  a  vesicle,  whilst  the  surrounding  tissues  become  red 
and  brawny.  Gangrene  occurs  at  the  focus  of  inflammation,  and 
around  this  a  ring  of  secondary  vesicles  forms.  Thus,  when  the 
so-called  pustule  is  fully  developed,  it  presents  a  very  character- 
istic appearance  (Fig.  39).     In  the  centre  there  is  a  dry  black 


152  GENERAL.    PATHOLOGY    OF    INJURIES, 

slough,  around  this  a  ring  of  vesicles,  and  around  this  again  an 
area  of  redness,  brawny  induration  and  much  cedema.  There  is, 
however,  but  little  pain  and  no  suppuration.  The  neighboring 
lymphatic  glands  may  now  become  enlarged  and  tender  ;  feverish 
symptoms  rapidly  assuming  a  typhoid  type  set  in,  and  the  patient 
dies  of  sudden  syncope,  exhaustion,  or  it  may  be  of  oedema  of  the 
glottis  when  the  disease  affects  the  neck.  Should  any  doubt  exist 
as  to  the  nature  of  the  disease,  it  will  be  cleared  up  by  examining 
the  contents  of  the  vesicles  for  the  bacillus. 

The  bacillus  anihracis  (Fig,  40)  is  a  rod-like  body,  straight  or 
sometimes  bent,  varying  from  TjTroo  to  ttiht  of  an  inch  in  length, 
and  presenting  at  times  a  delicate  transverse  mark  across  the 

middle.  It  multiplies  by  fission,  and 
when  in  contact  with  oxygen  by 
spores.  It  is  readily  killed  by  heat ; 
but  the  spores  resist  both  heat  and 
drying,  though  they  are  destroyed 
by  prolonged  boiling,  a  i  °/^  solution 
of  corrosive  sublimate  and  some 
other  antiseptics.  The  bacillus  is 
also  found  in  the  blood  and  in  vari- 
ous tissues  of  the  body  in  this  dis- 
ease. 

The   jyeaiment  consists    in    the 
free  excision  of  the  pustule.    If  this 
The  Anthrax  >'acii{^u^s-  ^  ■  i.ood.        j^  ^jy^e  in  time  the  patient  usually 

recovers.  Some  merely  scrape  with 
a  Volkmann's  spoon  ;  others  cauterize  the  wound,  after  excision 
or  scraping,  with  chloride  of  zinc  or  carbolic  acid.  Dusting  with 
ipecacuanha  powder  is  highly  spoken  of  by  some  surgeons.  When 
constitutional  symptoms  have  developed  the  strength  must  be 
supported  by  fluid  nourishment  and  by  stimulants  when  indicated. 
Sulphide  of  soda  in  ten-grain  doses  has  been  recommended  on 
account  of  the  beneficial  effect  it  exercises  in  splenic  fever  in 
animals. 

Actinomycosis  is  an  infective  disease  depending  upon  the  pres- 
ence in  the  tissues  of  a  micro-organism,  the  actinomyces. 

Cause. — 'J'he  disease,  which  is  prevalent  in  cattle,  may  be  trans- 
mitted to  man  either  directly  from  the  diseased  animal,  as  some- 
times occurs  in  cowmen,  or  indirectly  through  the  mcdimn  of  un- 
cooked meat  or  milk.  It  may  also  a])])arcntly  be  transmitted  l)y 
cereals.  A  grain  of  barley  has  been  foimd  in  several  growths. 
The  commonest  site  of  inoculation  is  through  a  carious  tooth,  but 
the  parasite  may  also  gain  admission  by  the  alimentary  and  respi- 
ratory tracts. 


ACTINOMYCOSIS. 


153 


ctinoinj  ces — the  ray  fungus 


Pathology. — The  actinomyces,  having  entered  the  tissues,  sets 
up  a  progressive  inflammation  leading  to  the  formation  of  granu- 
lation-tissue, connective  tissue  and  pus.  The  pus  contains  pale 
yellow,  or  sometimes  white  or  brown  grain?,  which  are  visible  to 
the  naked  eye  when  the  pus  is  spread  out  in  a  thin  layer,  the 
larger  grains  being  about  the  size  of  a  pin's  head.  These  grains 
are  seen,  on  microscopical  examination,  to  be  made  up  of  fine 
threads  of  mycelium,  with  radiating  club-shaped  bodies  at  the 
periphery.  The  "  clubs  "  are  at 
times  absent  and  are  believed  ^'<^ 

by  some,  who  regard  the  organ- 
ism as  a  species  of  cladothrix, 
to  be  involution  forms  and  not 
essential  to  the  disease  (Fig. 
41).   - 

In  cattle,  the  disease  affects 
chiefly  the  lower  jaw,  but  it  has 
also  been  met  with  in  the  upper 
jaw,  the  tongue,  the  respiratory 
and  alimentary  tracts,  and  in 
the  subcutaneous  and  intermus- 
cular tissues.  It  was  formerly 
included  under  the  names  of 
osteosarcoma,  wooden  tongue,  bone  cancer,  tubercle,  etc. 

Symptoms. — In  the  lower  jaw  it  is  commonly  met  with  about 
the  socket  of  a  carious  tooth.  A  great  deal  of  thickening  occurs 
in  the  surrounding  bone,  and  abscesses  are  formed  in  the  neigh- 
boring connective  tissue.  On  the  opening  of  the  abscesses  sin- 
uses are  left  leading  to  the  swelling,  which  is  found  to  consist  in 
part  of  tough  fibrous  tissue  and  in  part  of  soft  vascular  granula- 
tion-tissue filling  cavities  in  the  bone.  The  escaping  pus  contains 
the  grain-like  masses  of  the  fungus  which  are  characteristic  of  the 
disease.  When  the  disease  occurs  in  bones  other  than  the  jaw,  it 
gives  rise  to  a  growth  with  characters  similar  to  those  mentioned 
above.  When  it  begins  in  the  lung  it  may  spread  to  the  pleura 
and  then  extend  widely  in  the  chest  walls.  From  the  intestine  it 
may  invade  the  peritoneum  and  abdominal  walls.  In  whatever 
situation  it  begins,  however,  it  steadily  spreads  until  it  kills  either 
by  exhaustion  or  by  involving  some  vital  organ. 

Diagnosis. — The  disease  perhaps  most  resembles  tuberculous 
ulceration  or  a  fibro-  or  myxo-sarcoma  attended  by  profuse  sup- 
puration. The  presence  of  the  parasite  in  the  pus  will  clear  up 
any  doubt  as  to  the  nature  of  the  disease. 

Treatment. — The  only  efficient  treatment  is  the  complete  re- 
moval of  the  growth,  whilst  it  is  still  local,  by  excision  and  scrap- 


154  GENERAL    PATHOLOGY    OF    INJURIES. 

ing.  In  the  lower  jaw  this  has  been  attended  with  complete 
success.  When  the  disease  is  too  extensive  to  admit  of  removal, 
free  drainage  and  antiseptics  should  be  used  as  palliatives,  and 
iodide  of  potassium  given  internally.  This  drug  has  been  found 
of  great  value,  especially  in  cattle. 

General  Infective  Diseases. 

Septic.^isiia  OR  SEP  lie  INFECTION. — The  term  septicaemia  is  here 
restricted  to  the  condition  known  as  septic  infection  ;  septic  in- 
toxication, which  has  hitherto  been  included  under  the  term  sep- 
ticaemia, has  been  already  described  under  the  head  of  saprasmia. 
Septicaemia,  in  this  sense,  is  an  infectious  disease  due  to  inocula- 
tion with  a  specific  virus  which  multiplies  in  the  blood  and  is 
probably  of  the  nature  of  a  micro-organism. 

Cause. — The  essential  cause  is  the  introduction  of  the  specific 
virus  into  the  blood.  The  virus  may  be  derived  from  the  body  of 
another  patient  who  is  suffering  from  or  has  died  of  the  disease, 
and  may  be  conveyed  by  the  hands  of  the  surgeon  or  nurse,  or 
by  imperfectly  cleaned  instruments,  sponges,  etc.  'i'he  minutest 
quantity  of  the  poison  appears  to  be  sufficient. 

Pathology. — The  post-mortem  appearances  are  similar  to  those 
of  sapraemia.  There  is  a  like  condition  of  congestion  of  the  nerve- 
centres,  gastro-intestinal  tract  and  viscera,  with  petechiae  beneath 
the  serous  membranes,  and  staining  of  the  vessels  and  tissues. 
Micro-organisms,  both  micrococci  and  bacilli,  however,  are  found 
in  the  blood.  The  serous  cavities  often  contain  blood-stained 
serum,  and  pleurisy  and  pneumonia  may  at  times  be  present. 
The  spleen  is  generally  greatly  congested  and  enlarged. 

The  symptoms  are  also  similar  to  those  of  sapraemia  ;  indeed,  it 
is  often  impossible  to  differentiate  between  them.  Septicaemia, 
however,  may  be  suspected  when  there  is  evidence  of  infection 
from  some  source,  or  the  wound  is  of  such  a  size  as  to  render  it 
impossible  for  the  amount  of  septic  matter  necessary  to  set  up 
septic  intoxication  to  be  formed  in  it.  It  would,  moreover, 
appear  probable  that  the  two  diseases  may  at  times  coexist  in  the 
same  subject.  Septicaemia  begins  with  a  distinct  rigor,  which 
may  be  repeated,  followed  by  a  temperature  of  103°  to  104°  or 
higher.  The  symptoms,  the  chief  of  which  are  headache,  nausea, 
vomiting,  deliiium,  and  sometimes  diarrhaa,  may  run  the  same 
rapid  course  as  in  sapraemia,  the  patient  passing  into  a  state  of 
collapse ;  or  they  may  be  more  chronic  and  less  severe  in  degree 
though  similar  in  kind,  whilst  leucocytosis  and  petechial  eruptions 
of  the  skin,  or  bronchitis,  pneumonia,  pleurisy,  or  pericarditis 
may  supervene. 


py^pMiA.  155 

Treatment. — Little  can  be  done  in  the  way  of  curative  treat- 
ment beyond  preventing  the  introduction  of  more  poison  by 
taking  the  same  local  means  to  disinfect  the  w^ound  as  were  men- 
tioned under  saprsemia.  The  same  good  effects,  however,  must 
not  be  expected,  as  the  poison  once  introduced  multiplies  indefi- 
nitely, and  hence  the  disease  is  almost  invariably  fatal.  Large 
doses  of  quinine  or  salicylic  acid  or  sulphite  of  potash,  however, 
may  be  given,  whilst  the  strength  should  be  supported  by  fluid 
nourishment  and  stimulants. 

Pyemia  is  distinguished  from  septicaemia  by  the  formation  of 
secondary  {?netastatic)  abscesses  in  various  tissues  and  organs  of 
the  body.  It  received  its  name  on  the  erroneous  supposition 
that  it  was  due  to  the  entrance  of  pus  into  the  blood,  seeing  that 
it  generally  originates  in  connection  with  a  suppurating  wound, 
and  is  later  attended  with  purulent  collections  in  various  parts  of 
the  body.  By  some  it  is  still  regarded  as  a  later  stage  of  septi- 
caemia, as  previous  to  the  formation  of  the  abscesses  the  two  dis- 
eases are  often  clinically  indistinguishable.  Recent  investigations, 
however,  point  to  pyaemia  being  a  disease  distinct  from  both 
septicaemia  and  sapraemia,  and  have  further  made  it  appear  prob- 
able that  the  train  of  symptoms  known  as  pyaemia  are  due  to 
several  different  pathological  processes. 

Cause. — The  immediate  cause  is  no  doubt  the  entrance  of  a 
poison  into  the  blood,  and  since  pyogenic  micrococci  have  been 
found  in  the  wound,  the  thrombosed  veins  leading  from  the 
wound,  in  the  blood,  the  tissues,  and  the  metastatic  abscesses,  it 
is  now  held  that  these  organisms  are  essential  factors  in  the  pro- 
duction of  the  condition  known  as  pyaemia.  Pyjemia,  however, 
is  seldom  developed  except  where  the  patient  is  exposed  to  un- 
favorable hygienic  conditions,  amongst  which  may  be  especially 
mentioned  overcrowding  in  ill-ventilated  and  badly-drained  hos- 
pitals, particularly  where  a  large  number  of  suppurating  and  foul 
wounds  are  congregated  together  in  the  same  ward ;  whilst  the 
general  debility  induced  by  insanitary  dwellings,  poor  living, 
town  life,  and  the  abuse  of  alcohol,  in  that  it  lowers  the  resisting 
power  of  the  tissues,  further  predisposes  to  the  disease.  Pyaemia 
is  generally  developed  in  connection  with  a  wound  which  has 
reached  the  stage  of  suppuration  and  has  not  been  properly 
drained  and  kept  aseptic.  It  is  probable,  therefore,  that  the 
septic  products  entering  the  system  with  the  pyogenic  micrococci 
further  lower  the  resisting  power  of  the  tissues.  The  micrococci 
having  gained  admission  to  the  wound,  infect  the  thrombi,  filling 
the  veins  leading  from  it,  and  are  carried  away  with  detached 
portions  of  the  thrombi  into  the  venous  circulation.  The  emboli 
become  lodged  in  the  capillaries  of  the  tissues  and  organs,  and 


156  GENERAL    PATH(JLOGY    OF    INJURIES. 

being  infected  with  the  pyogenic  organisms  and  impregnated 
with  septic  ptomaines  from  the  wound,  set  up  suppuration  in  the 
tissues  around  the  vessels  in  which  they  lodge.  In  other  instances 
it  is  believed  that  the  pyogenic  micrococci  may  enter  the  circula 
tion  in  such  masses  that  they  are  sufficient  in  themselves  without 
the  presence  of  any  clot  to  plug  the  small  vessels,  and  here  in 
like  manner  to  cause  secondary  suppuration.  There  appear  to 
be,  therefore,,  two  chief  elements  at  work,  the  pyogenic  cocci 
giving  rise  to  the  disseminated  suppurations,  and  the  septic 
ptomaines  developed  in  the  wound  or  generated  by  the  cocci 
themselves,  poisoning  the  whole  system.  Pyaemia  is  especially 
common  after  wounds  involving  bone,  owing  to  the  liability  of  the 
large  patulous  veins  of  bone  to  become  filled  with  purulent 
thrombi,  portions  of  which  are  readily  carried  away  by  the  blood- 
stream. Hence  the  frequency  of  pyaemia  after  injuries  of  the 
cranium  involving  the  diploe,  compound  fractures,  amputations, 
and  excisions,  when  antiseptics  and  drainage  are  neglected. 
Again,  the  poison  may  be  developed  in  decomposing  portions  of 
the  placenta  left  after  childbirth,  and  may  then  enter  the  blood 
by  infecting  the  thrombi  in  the  uterine  veins.  Or  it  may  be 
formed  in  connection  with  operations  on  the  genito-urinary  tract, 
on  account  of  the  difficulty  of  keeping  such  wounds  aseptic. 
Pyaemia,  moreover,  is  especially  frequent  after  infective  osteo- 
mychtis  and  infective  periostitis,  even  before  the  suppurating  cavity 
is  opened  and  exposed  to  the  outer  air.  It  may  also  occur  in 
connection  with  erysipelatous  wounds,  diffuse  cellulitis,  and  hos- 
pital gangrene,  and  sometimes  after  gonorrhoea,  ulceration  of  the 
intestines  in  typhoid  fever  and  dysentery,  and  ulcerative  endo- 
carditis. Very  occasionally  pysemia  follows  the  most  trivial 
operation  or  injury,  as  the  subcutaneous  division  of  a  tendon  or  a 
portion  of  fascia.  Here  it  is  probably  the  result  of  the  introduc- 
tion of  micro-organisms  at  the  time  of  the  operation.  At  times 
no  local  source  of  infection  can  be  discovered ;  the  disease  is 
then  spoken  of  as  idiopathic  pycemia,  and  it  is  believed  that  the 
pyogenic  micro-organisms  gain  admission,  as  in  infective  osteo- 
myelitis, ])eriostitis,  and  ulcerative  endocarditis,  through  a 
mucous  surface. 

f'atlwloi:;^}'. — 'j'he  post-mortem  appearances  are  similar  to  those 
in  se[)tic?e:nia,  f>/us  purulent  collections  in  one  or  more  situations, 
or  disseminated  through  the  body  as  multiple  small  abscesses. 
Thus,  there  is  the  same  rapid  tendency  to  ])utrefaction,  disinte- 
gration of  red  blood-corpuscles,  staining  of  the  vessels  and  tissues, 
minute  extravasations  {petechice)  beneath  the  serous  membranes 
and  in  the  skin,  congestion  of  the  viscera,  enlargement  of  the 
spleen,  and  in  many  cases  the  presence  of  micro-organisms  in  the 


PY/EMIA. 


157 


Fig.  42. 


blood  and  various  tissues  and  organs.     The  body  is  emaciated, 
and  the  skin  yellowish  and  earthy  in  appearance. 

The  purulent  collections  may  be  found  in  the  serous  cavities,  in 
the  viscera,  in  the  joints  and  indeed  throughout  the  body  gener- 
ally. There  may  be  one  or  more  moderate-sized  collections  of 
pus  ;  or  an  organ,  as  the  lung,  may  be  riddled  by  a  number  of 
small  abscesses  varying  in  size  from  a  pea  to  a  nut.  The  visceral 
abscesses  are  most  common  in  the  lungs,  then  in  the  liver,  and 
next  in  the  spleen,  kidneys  and  brain.  They  are  situated  in  the 
periphery  of  the  organs,  /.  c,  in  the  situation  of  the  smallest  cap- 
illaries. Where,  however,  pyaemia  follows  a  lesion  of  the  rectum, 
the  abscesses  are  generally  found  in  the  liver,  since  most  of  the 
blood  from  the  rectum  passes  first  through  that  organ.  The  pus  is 
sweet,  rarely  foetid,  and  may  resemble  ordinary  pus,  or  it  may  be 
thin  and  watery.  It  always  contains  pyogenic  micrococci.  When 
there  is  a  wound  it  is  usually  found  unhealthy  or  putrescent,  and 
surrounded  by  an  inflammatory  area  ;  micrococci  are  present  in 
it.  The  veins  leading  from  the  wound  are  usually  filled  with 
thrombi,  which  are  generally,  though  not  invariably,  undergoing 
purulent  softening,  and  then  contain  micrococci. 
Where  the  pyaemia  has  originated  in  infective 
osteomyelitis,  infective  periostitis,  or  in  a  wound 
involving  bone,  the  veins  in  the  medulla  of  the 
bone,  and  those  leading  from  the  bone  are 
usually  also  found  filled  with  purulent  thrombi. 
If  the  affected  veins  are  followed  towards  the 
heart,  the  end  of  the  thrombus  will  often  be 
seen  projecting  into  the  blocd-current  in  the 
larger  vein  at  the  spot  where  the  smaller  joins 
it  (Fig.  42).  Lastly,  coccus  colonies,  i.  e.,  collec- 
tions of  micrococci,  are  found  in  the  various  tis- 
sues and  organs. 

A  consideration  of  the  above  morbid  appear- 
ances makes  it  appear  probable  that  the  metasta- 
tic abscesses  may  be  produced  in  several  ways  : 
I.  Thrombosis  of  the  veins  leading  from  the 
wound  is  set  up  by  one  or  more  of  the  conditions  that  commonly 
produce  thrombosis,  such  as  suppuration  around  a  vein,  an  abscess 
breaking  into  a  vein,  death  of  the  part  i'rom  which  the  vein  runs, 
etc.  The  thrombus  becomes  impregnated  with  the  septic  pro- 
ducts forming  in  the  wound,  and  with  the  pyogenic  micrococci 
introduced  from  without.  The  septic  and  infective  changes  ex- 
tend up  the  thrombus  ;  portions  of  the  thrombus  where  it  projects 
into  a  larger  vein  are  detached  by  the  force  of  the  blood-stream 
in  the  larger  vein  (see  P'ig.  42),and  are  carried  away  in  the  blood, 


Thrombosed  vein. 
The  thrombus  is 
seen  projecting 
from  the  smaller 
into  the  larger 
vein. 


158  GENERAL   PATHOLOGY    OF   INJURIES. 

and  become  lodged  in  the  capillaries  of  the  lungs  or,  possibly, 
escaping  through  them,  in  the  capillaries  of  other  parts  of  the 
body.  These  emboli,  being  of  a  septic  and  infective  nature,  in- 
stead of  leading  to  the  changes  which  follow  ordinary  embolism, 
give  rise  to  septic  and  infective  inflammation  terminating  in  sup- 
puration and  abscess  {primary  embolic  abscesses).  2.  Masses  of 
micrococci  which  have  gained  entrance,  either  directly  through  a 
wound  or  indirectly  through  a  mucous  membrane,  as  in  the  case 
of  infective  periostitis,  osteomyelitis,  etc.,  are  carried  from  the 
primary  seat  of  disease  by  the  lymphatics  or  blood-stream,  and 
become  lodged  in  the  capillaries  of  the  various  tissues  and  organs. 
There  blood-corpuscles  aggregate  around  them,  thus  forming  a 
thrombus,  which  softens  and  sets  up  infective  inflammation  and 
suppuration.  3.  Portions  of  the  softened  thrombus  in  the  lung- 
capillaries  become  detached,  and  are  carried  by  the  blood-stream 
to  other  parts  of  the  body,  where  they  in  turn  form  emboli,  which 
also  set  up  similar  infective  inflammation  and  suppuration  {^sec- 
ondary embolic  abscesses).  4.  The  diff'use  punUent  collections  in 
the  serous  and  synovial  cavities  are  thought  as  a  rule  to  depend 
upon  the  poisoned  condition  of  the  blood  and  the  presence  of 
micrococci,  not  upon  emboli. 

The  syvipfoms  usually  set  in  with  a  rigor,  generally  a  severe  one, 
during  which  the  temperature  rises  to  103°,  104°,  or  even  higher. 
Profuse  sweating  follows.  The  rigors  are  repeated  from  time  to 
time.  The  temperature  chart  rei)resents  the  same  series  of  long 
up  and  down  strokes  characteristic  of  hectic  fever,  only  differing 
in  that  the  morning  temperature  in  pyaemia  seldom  reaches  nor- 
mal. The  pulse  is  quick  ;  the  tongue  is  red  01  glazed,  and  later, 
dry  and  brown  ;  wasting  rapidly  sets  in  ;  the  skin  often  assumes 
an  earthy  or  jaundiced  hue  ;  the  face  is  anxious,  perhaps  flushed, 
or  pale  ;  extravasations  from  the  capillaries  of  the  skin  occur,  pro- 
ducing petechiae ;  and  other  eruptions,  though  less  common,  as 
patches  of  erythema,  may  appear  from  time  to  time,  with  aphthae 
or  ulceration  of  the  fauces.  The  breath  and  the  exhalations  of  the 
body  have  a  peculiar  sweet  odor,  and  albumen  may  be  found  in 
the  urine.  At  about  the  end  of  a  week  metastatic  abcesses  form 
in  various  parts,  as  the  lung,  liver  and  joints ;  or  diffuse  suppura- 
tion may  be  set  up  in  the  serous  cavities,  and  signs  of  pericarditis, 
pleurisy,  or  peritonitis  ensue.  Diarrhoea  sets  in,  then  delirium, 
and  the  patient  dies  exhausted  usually  during  the  second  week. 
In  the  meanwhile,  the  wound,  if  one  exists,  is  generally  foul  and 
suppurating,  though  later  it  may  become  dry  and  cease  to  form 
pus;  in  some  chronic  cases,  which  are  rare,  however,  the  wound 
may  heal.  'J'he  prognosis  is  extremely  unfavorable  ;  acute  cases 
are  always  fatal,  each  rigor  making  the  chance  of  recovery  more 


GLANDERS.  1 59 

hopeless.  At  times,  however,  the  disease  may  run  a  chronic 
course  {chronic  pyceinia),  differing  from  the  acute  in  degree 
rather  than  in  kind.  Thus  the  rigors  are  less  frequent  or  none 
may  occur.  The  viscera,  as  a  rule,  are  not  affected,  and  the  ab- 
scesses show  a  special  predilection  for  the  joints.  The  patient 
may  die  after  some  weeks,  or  may  linger  for  some  months,  or  very 
slowly  recover  after  one  or  more  relapses,  with  probably  stiffness 
of  one  or  more  joints.  Or  he  may  subsequently  die  of  phthisis, 
albuminuria,  or  lardaceous  disease. 

Treatment. — Little  or  nothing  can  be  done  in  the  way  of  treat- 
ment in  acute  cases,  when  once  the  pyjemic  process  is  established, 
beyond  supporting  the  strength  by  fluid  nourishment  and  stimu- 
lants, opening  abscesses  as  they  are  formed,  and  placing  the 
patient  under  the  most  favorable  hygienic  conditions  possible. 
Measures  should,  of  course,  be  taken  to  drain  the  wound  and 
render  it  aseptic  if  this  has  been  neglected.  Quinine  in  large 
doses  is  generally  advised,  but  little  must  be  expected  from  it. 
In  infective  osteomyelitis  and  periostitis,  amputation  through  the 
joint  above  the  affected  bone  should  be  done  if  pysemia  appears 
imminent  but  has  not  fully  declared  itself.  In  chronic  cases, 
when  convalescence  has  ensued,  a  sea-voyage  or  residence  at  Aix- 
la-Chapelle  or  other  suitable  spa  may  be  of  benefit. 

Glanders  is  a  specific  infective  disease  common  amongst 
horses,  and  occasionally  comm.unicated  to  man  by  inoculation 
through  a  wound  or  the  unbroken  mucous  membrane.  The 
poison  is  believed  to  be  a  specific  form  of  micro-organism,  the 
bacillus  mallei,  since  this  bacillus  after  several  cultivations  retains 
the  power  of  reproducing  the  disease  in  the  horse.  The  disease 
may  run  an  acute  or  chronic  course.  It  is  nearly  always  acute  in 
man  and  chronic  in  the  horse.  The  acute  form  is  characterized : 
( I )  by  a  thin  serous  discharge,  rapidly  becoming  foul,  purulent, 
and  sanious,  from  the  nasal  mucous  membrane,  with  enlargement 
of  the  submaxillary  glands;  (2)  by  a  pustular  eruption,  resemb- 
ling that  of  small-pox,  on  the  skin  and  mucous  membrane  of  the 
respiratory  and  digestive  tract;  and  (3)  by  the  formation  of 
circumscribed  nodules  in  the  lymphatics  of  the  subcutaneous  and 
muscular  tissue,  which  usually  soon  break  down  into  abscesses  and 
foul  ulcers.  These  signs  are  ushered  in  and  accompanied  by 
fever,  which  rapidly  assumes  a  typhoid  type,  and  is  sometimes 
preceded  by  a  rigor.  Symptoms  of  pneumonia  or  pleurisy,  or 
vomiting  and  diarrhoea  ensue,  according  as  the  respiratory  or 
alimentary  tract  is  chiefly  affected,  and  death  usually  takes  place 
within  a  week  from  saprsemia,  septicaemia,  or  pysemia.  In  the 
chi'onic  form  the  constitutional  symptoms  are  less  sev'ere,  and  the 
patient  may  linger  for  months,  or  even  recover. 


l6o  GENERAL   PATHOLOGY   OF   INJURIES. 

In  the  horse  the  disease  is  spoken  of  by  veterinary  surgeons  as 
"/cTny"  when  the  lymphatic  vessels  and  glands  are  principally 
affected,  the  swellings  opposite  the  valves  in  the  Ivmphatics  form- 
ing the  so-called  '■\farcy-buds ;''  and  2,% glanders,  when  the  disease 
falls  chiefly  upon  the  nasal  mucous  membrane.  In  man  ihe  two 
processes  generally  occur  together,  as  above  described. 

Treatment. — Beyond  supporting  the  patient's  strength  with 
concentrated  fluid  nourishment,  opening  abscesses  as  they  occur, 
dressing  the  ulcers  antiseptically,  and  syringing  out  the  nasal 
chambers  with  antiseptic  lotions,  little  or  nothing  can  be  done,  as 
no  treatment  appears  to  have  been  hitherto  of  any  avail.  It  has 
been  recently  shown  that  a  chemical  substance  {ina/kin)  present 
in  the  artificial  cultures  of  the  glanders  bacilli  produces  no  re- 
action when  injected  into  the  tissues  of  healthy  animals  :  but 
when  injected  into  the  tissues  of  animals  affected  with  glanders 
a  decided  rise  of  temperature  takes  place.  A  means  of  making 
an  early  diagnosis  is  thus  afforded,  and  by  its  use  the  disease 
might  probably  be  stamped  out  of  infected  stables. 

Hydrophobia  is  a  specific  infective  disease,  always  propagated 
by  inoculation,  and  probably  due  to  a  specific  micro-organism. 
It  has  received  its  name  from  the  prominent  symptoms  which  the 
pharyngeal  spasms  produce.  It  is  called  rabies  in  dogs  because 
no  fear  of  water  is  shown,  and  because  in  them  there  may  be 
great  excitement.  The  disease  is  generally  received  by  man  from 
the  dog,  occasionally  from  the  wolf,  and  more  rarely  from  the  cat 
or  fox,  and  by  these  animals  it  may  be  given  to  horses,  deer,  etc. 
The  moculation  is  generally  through  a  bite  by  which  the  saliva 
containing  the  virus  reaches  the  lymphatics.  At  times  it  has 
occurred  through  a  scratch  which  has  been  only  licked  by  the 
affected  animal,  and  once  through  making  a  post  mortem  exami- 
nation on  a  subject  who  had  died  of  the  disease.  Of  all  persons 
bitten  by  rabid  animals,  about  15  per  cent,  only  suffer  from  the 
disease,  a  fact  which  probably  in  chief  part  depends  upon  the 
saliva  being  wiped  off  the  teeth  as  they  pass  through  the  clothes. 
The  most  dangerous  wounds  are  those  on  the  face  and  hands,  and 
on  the  bare  legs  of  children,  the  average  mortality  of  bites  on  the 
face  being  as  high  as  60  to  80  per  cent.  Multiple  and  lacerated 
wounds  are  naturally  most  to  be  feared,  as  inoculation  in  them  is 
more  likely  to  take  place.  Also  the  nearer  the  bite  is  to  the 
central  nervous  system,  the  more  easily  and  rapidly  does  the 
poison  reach  the  brain  and  begin  to  take  effect.  Indeed  the  only 
certain  method  of  jjroducing  the  disease  in  animals  is  by  inocula- 
ti:m  under  the  dura  mater.  It  was  the  discovery  of  this  fact 
which  enabled  M.  Pasteur  to  make  his  investigations. 

'i'he  average  period  of  incubation  varies  from  two  weeks  to  six 


HYDROPHOBIA.  l6l 

months.  Although  it  is  said  that  the  incubation  period  has  been 
as  short  as  two  days,  and  as  long  as  twenty  years,  two  weeks  to 
two  years  may  practically  be  given  as  its  limits.  There  are  no 
symptoms  during  this  period.  The  vesicles  or  lyssae  said  to  occur 
under  the  tongue  from  the  third  to  th€  ninth  day  after  the  bite 
do  not  appear  to  be  a  constant  phenomenon.  The  virus  has  no 
influence  on  the  healing  of  the  wound,  the  bite  of  a  mad  dog 
healing  like  other  wounds,  either  by  first  intention,  or  if  the 
tissues  are  badly  lacerated,  slowly  and  painfully. 

Seeing  therefore  that  there  are  no  symptoms  during  the  incu- 
bation period,  and  that  in  the  early  stages  of  rabies  there  are  no 
xvAktA-t.^t  post-mortem  signs,  the  only  way  of  ascertaining  if  the 
bite  is  that  of  a  mad  dog  is  to  watch  the  animal.  If  the  dog  is 
killed  at  once  the  patient  will  suffer  much  mental  anxiety.  He 
must  wait  for  three  weeks  before  the  point  can  be  determined  by 
inoculation  experiments  on  rabbits,  or  he  may  undergo  Pasteui's 
treatment  unnecessarily.  Moreover,  to  wait  three  weeks  may  be 
too  late  for  wounds  of  the  face.  Every  suspected  dog,  therefore, 
should  be  confined  in  a  strong  cage.  If  mad  he  will  show  ad- 
vancing symptoms,  and  die  in  three  or  four  days.  It  is  import- 
tant,  therefore,  to  recognize  the  symptoms  of  rabies  in  the  dog. 

Symptoms  of  rabies. — The  earhest  symptoms  are  restlessness, 
dulness,  and  a  tendency  to  shun  the  light.  The  dog  often  roves 
far  and  wide,  and  has  a  morbid  appetite  for  pieces  of  stick,  hay, 
stones-,  etc.  In  the  next  stage  he  may  rush  wildly  about,  biting 
other  dogs,  inanimate  objects,  or  men,  frequently  those  to  whom 
he  has  been  previously  attached.  The  appetite  is  lost ;  there  is 
a  desire  to  drink,  and  the  muzzle  is  put  into  the  water,  but  none 
is  taken.  Finally  he  becomes  paralyzed,  the  lower  jaw  begins  to 
drop,  the  bark  changes  to  a  characteristic  hoarse  howl  from 
pharyngeal  paralysis ;  next  the  limbs  fail,  and  finally  the  muscles 
of  respiration.  Sometimes,  however,  advancing  paralysis  is  the 
only  symptom,  the  power  of  barking  being  then  lost.  This  form 
of  the  disease  is  called  dumb  rabies. 

Fost-mortem  signs  of  rabies. — The  stomach  contains  hay,  sticks, 
stones,  etc.,  and  its  mucous  membrane  is  congested  and  scattered 
over  with  small  hceraorrhages.  The  trachea  is  congested  and  may 
also  be  dotted  over  with  small  haemorrhages.  The  nervous  sys- 
tem, especially  the  cord  and  medulla,  show  signs  of  acute  myelitis. 
This  begins  with  an  exudation  of  leucocytes  into  the  sheaths  of 
dilated  vessels,  then  haemorrhage  and  finally  softening.  If  a 
portion  of  the  medulla  or  cord  is  required  for  inoculating  pur- 
poses a  piece  should  be  placed  at  once  in  a  20  p.  c.  solution  of 
glycerine  and  ^pt  there  for  three  or  four  days  to  kill  sepiir 
micro-organisms ;  an  emulsion  is  then  made  and  a  drop  or  two 
7* 


1 52  GENERAL    PATHOLOGY    OF    INJURIES. 

injected  under  the  dura  mater  of  a  rabbit,  which  will  die  in  from 
eighteen  to  twenty-one  days,  showing  first  excitement,  and  then 
paralysis  of  the  hinder  limbs,  extending  later  to  the  fore-limbs 
and  head. 

Pathology  of  hydrophobia. — The  ^x\Vi(:v^?\  post-mortetn  changes 
have  been  found  in  the  medulla,  especially  about  the  region  of 
the  glosso-pharyngeal,  pneumo-gastric  and  hypo-glossal  nuclei, 
and  in  the  cerebral  cortex.  They  consist  in  the  infiltration  of 
the  peri  vascular  sheaths  with  leucocytes,  thrombosis  of  the 
medium-sized  vessels,  small  haemorrhages,  and  degeneration  of 
the  neive  cells ;  in  short,  as  in  animals,  of  an  acute  myelitis. 
The  theory  now  generally  held  with  regard  to  the  pathology  of 
the  disease  is  that  the  poison,  after  remaining  for  a  variable  time 
dormant  in  the  wound,  multiphes  or  matures ;  and  then  that 
either  it  or  its  products  slowly  enter  the  blood  and  set  up  a 
specific  inflammation  in  the  medulla  and  cerebral  cortex,  whereby 
their  power  of  resistance  to  reflex  irritation  is  diminished  or  lost. 
Hence  the  occurrence  of  the  spasms  on  the  slightest  provocation. 
Finally,  that  should  the  patient  not  succumb  to  spasm  of  the 
glottis  or  muscles  of  respiration,  the  affected  nerve-centres  be- 
come exhausted  and  no  longer  respond  at  all  to  the  reflexes 
necessary  to  carry  on  life,  and  the  heart's  action  in  consequence 
ceases.  The  nature  of  the  poison  is  not  known,  though  the  be- 
lief is  gaining  ground  that  the  disease  depends  in  some  way  upon 
a  micro-organism,  since  rod-like  bodies  have  been  diseoveled  in 
connection  with  the  haemorrhage  lesions  in  the  cerebral  cortex, 
and  a  micro- organism  has  been  isolated  by  inoculating  fowls  with 
the  virus  taken  from  rabid  animals. 

Symptoms  of  hydropho/>ia. — At  first  there  may  be  pricking  pain, 
perhaps  some  redness  and  tumidity,  at  the  site  of  the  wound, 
which  has  generally  long  since  healed.  The  patient,  if  an  adult, 
has  often  much  mental  anxiety,  and  with  the  onset  of  the  symp- 
toms may  become  melancholic.  As  the  disease  becomes  fully 
developed  the  symptoms  ])oint  to  disturbance  in  the  medulla, 
es])ecial]y  about  the  centres  for  deglutition  and  respiration. 
Thus  there  is  increasing  dififirulty  in  sw^illowing  in  consequence 
of  pharyngeal  spasm,  and  a  peculiar  click  in  respiration  in  conse- 
quence of  spasm  of  the  diaphragm.  The  pharyngeal  spasms  are 
at  first  only  excited  by  attempts  to  swallow,  but  subsequently  the 
sight  ot  water  and  the  sound  of  its  trickling  from  one  vessel  to 
another,  a  blast  of  cold  air,  or  a  sudden  light,  is  sufficient  to  set 
them  up.  Swallowing  is  now  quite  impossible,  and  viscid  saliva 
is  forcibly  hawked  up  and  expectorated  about.  The  spasms 
which  begin  in  the  pharynx  extend  to  the  muscles  of  respiration 
and  then  become  general ;  the  pain  is  agonizing,  and  the  patient 


TREATMENT  OF  HYDROPHOBIA.  1 63 

may  have  hallucinations  or  violent  delirium,  but  often  remains 
sensible  of  his  dreadful  condition  to  the  end.  Paralysis  finally 
ensues,  and  death  usually  occurs  from  involvement  of  the  respira- 
tory muscles.  The  spasms  sometimes  diminish  as  the  paralysis 
advances,  and  the  patient  may  sink  into  a  delusive  calm,  during 
which  the  power  of  swallowing  may  be  regained.  Sometimes  the 
chief  symptom  throughout  is  advancing  paralysis.  Such  cases 
resemble  dumb  rabies  of  dogs. 

Death  may  be  due  in  the  earlier  stages  to  spasm  of  the  glottis 
or  muscles  of  respiration ;  later  to  paralysis  of  the  muscles  of 
respiration  or  to  exhaustion. 

Diagnosis. — The  into'mittent  character  of  the  spasms  {clonic 
spasms),  the  hallucinations,  and  the  escape  of  viscid  saliva  from 
the  mouth,  will  generally  serve  to  distinguish  hydrophobia  from 
tetanus  following  the  bite  of  a  dog,  and  from  false  or  hysterical 
hydrophobia.  In  the  latter  case,  too,  the  convulsions  will  cease 
if  the  patient  is  put  under  chloroform. 

The  prognosis  when  the  disease  has  once  developed  is  hopeless. 
There  is  no  authentic  case  of  recovery  from  hydrophobia. 

The  treatment  may  be  divided  into  the  preventive  and  paUia- 
tive.  Preventive  treatment. — If  the  patient  is  seen  immediately 
after  the  bite,  we  should  endeavor  to  remove  the  poison  from  the 
wound,  or  else  destroy  it.  This  may  be  attempted  by  suction,  a 
procedure  which  appears  to  be  quite  safe  provided  there  is  no 
crack  or  abrasion  about  the  lips  or  tongue ;  or  if  at  hand,  a  cup- 
ping-glass may  be  applied.  The  parts  should  afterwards  be  ex- 
cised or  thoroughly  cauterized,  the  best  caustics  being  nitric  acid, 
nitrate  of  silver,  caustic  potash,  and  pure  carbolic  acid.  It  has 
been  advised  that  if  the  wound  has  already  healed  when  the 
patient  is  seen  the  cicatrix  should  be  cut  out ;  but  it  is  more  than 
questionable  if  this  procedure  is  of  any  value,  especially  as  it  ap- 
pears that  if  inoculation  by  M.  Pasteur's  method  is  resorted  to 
before  symptoms  come  on,  the  disease  may  be  effectually  pre- 
vented from  developing. 

Pasteur's  treatment. — This  consists  in  obtaining  a  virus  of  fixed 
strength  and  then  attenuating  it  so  that  it  can  be  safely  inoculated. 
To  obtain  the  fixed  virus  the  disease  is  transmitted  through  a 
series  of  rabbits,  the  period  of  incubation  becoming  less  and  less 
as  the  virus  increases  in  intensity,  till,  after  passing  through  up- 
wards of  eighty  rabbits,  the  period  of  inoculation  is  found  to  be 
constant  and  the  virus  of  maximum  intensity.  A  rabbit  inoculated 
with  this  fixed  virus  always  develops  symptoms  on  the  yth  day 
and  dies  on  the  loth.  To  attenuate  the  virus  a  portion  of  spinal 
cord  of  a  rabbit  inoculated  with  the  fixed  virus  is  suspended  in  a 
sterilized  bottle  over  caustic  potash.     As  the  cord  dries  the  virus 


1 64  GENERAL   PATHOLOGY    OF    INJURIES. 

becomes  less  virulent,  so  that  after  two  days'  drying  a  rabbit  in- 
oculated with  it  dies  in  from  1 1  to  17  days ;  after  7  days'  drying 
from  23  to  29  days;  after  11  days'  drying  from  30  to  35  days; 
until  after  12,  13,  or  14  days'  drying,  its  virulence  is  completely 
lost.  An  emulsion  is  made  of  0.5  centigrams  of  spinal  cord  in  2 
cubic  centimeters  of  sterilized  beef-tea,  and  a  drop  or  two  is  sub- 
cutaneously  injected  under  the  skin  of  the  abdomen  or  flank. 
The  cords  are  used  in  an  ascending  series  from  the  14th  or  15th 
day  of  drying  upwards,  until  on  the  9th  day  of  treatment  a  cord 
which  has  been  dried  for  only  3  days  is  used.  The  treatment  is 
continued  for  16  days.  The  above  is  known  as  the  Simple  method. 
For  face-bites  a  more  rapid  method  has  been  found  necessary  to 
prevent  the  disease.  In  this,  which  is  called  the  Intensive  method, 
a  cord  of  only  three  days'  drying  is  used  on  the  6th  day,  and  the 
treatment  is  continued  with  two  days'  intermission  until  the  20th 
day.  This  method,  however,  appears  to  be  som.ewhat  dangerous, 
a  few  patients  so  treated  having  died  with  symptoms  of  the  para- 
lytic form  of  the  disease  similar  to  that  induced  in  animals  by 
inoculation. 

Palliative  treatment. — When  hydrophobia  has  supervened,  all 
that  can  be  done  is  to  relieve  symptoms.  Thus  the  patient 
should  be  placed  in  a  darkened  room,  and  every  source  of  irrita- 
tion that  may  cause  spasm  avoided.  Opium  and  morphia  should 
also  be  given  for  the  same  purpose.  Chloral,  chloroform,  eserine, 
pilocarpine,  curare,  and  many  other  drugs  have  been  given  ;  but 
all  are  useless,  and  some,  as  chloroform  and  curare,  are  not  unat- 
tended with  danger. 

Tetanus  is  a  disease  in  which  the  voluntary  muscles  are  thrown 
from  time  to  time  into  a  state  of  intense  spasm,  whilst  they  re- 
main in  the  intervals  in  a  condition  of  constant  contraction 
{tonie  spasm). 

Cause. — Tetanus  was  formerly  attributed  to  a  lesion  of  the 
peripheral  nerves  ;  but  recent  researches  have  shown  that  it  is  an 
infective  disease  depending  upon  a  specific  virus  generated  by  the 
growth  of  a  micro-organism  {.bacillus  ietani).  It  is  especially 
prevalent  in  hot  climates,  and  amongst  the  negro  races ;  it  occurs 
more  often  in  men  than  in  women,  and  in  military  than  in  civil 
practice.  It  is  seldom  met  wdth  in  this  country  except  in  con- 
nection with  a  wound,  and  is  especially  common  after  lacerated 
and  punctured  wounds  and  burns ;  but  it  has  been  known  to  oc- 
cur after  every  kind  of  wound,  from  a  mere  scratch,  or  the  liga- 
ture of  a  pile  or  the  umbilical  cord,  to  amj)utation  of  the  thigh  or 
other  capital  operation.  'J'etanus,  however,  has  been  more  often 
observed  to  occur  when  the  wound,  whatever  its  cause  and  char- 
acter, is  in  a  septic  condition.     Exposure  to  cold,  damp,  and 


TETANUS. 


^65 


Fig.  43. 


sudden  changes  of  temperature  were  believed  to  influence  its 
production,  and  where  tetanus  occurs,  as  it  sometimes  does,  in- 
dependently of  a  wound,  were  regarded  by  some  as  the  essential 
cause.  It  is  more  probable,  however,  that  such  conditions 
merely  act  as  depressing  agents,  and  that  the  micro-organism  in 
these  cases  gains  admission  through  a  scratch  or  abrasion  which 
has  been  overlooked,  or  by  absorption  through  the  unbroken 
mucous  or  cutaneous  surface. 

Tetanus  is  inoculable  from  animal  to  animal,  and  probably  from 
animals  to  man,  since  a  veterinary  surgeon  has  lately  died  of 
tetanus  after  making  a  post-moriein  examination  on  a  horse  dead 
of  the  disease. 

Pathology. — But  little  is  discoverable  on  post-mortevi  examina- 
tion. At  times  the  nerves  leading  from  the  wound  have  been 
found  congested,  at  other  times  un- 
altered in  appearance.  Hyperaemia 
of  the  medulla  and  cord,  exudation 
in,  and  degeneration  of  the  grey 
matter,  and  haemorrhages  in  the 
white  columns,  have  been  noted  in 
some  cases  \  whilst  in  others  noth- 
ing abnormal  in  the  nerve-centres 
has  been  discovered.  The  older 
view  of  the  pathology  of  tetanus 
was  that  the  disease  depended  upon 
a  primary  lesion  of  the  peripheral 
nerves,  and  that  the  irritation  thus 
produced  was  conveyed  by  the  in- 
jured nerve  to  the  nerve-centres, 
where  it  became  persistent,  and 
continuing  after  the  real  cause  had  been  removed,  gave  rise  to 
muscular  spasm  in  various  parts  of  the  body.  The  modern  view 
is  that  the  disease  is  due  to  a  specific  virus  which  affects  the  me- 
dulla and  cord  in  a  way  similar  to  strychnine.  The  virus  {tetanin 
tetano-toxin)  is  a  chemical  compound,  but  according  to  the  re- 
searches of  Vaillard  and  Vincent,  is  neither  an  alkaloid  nor  an 
albumose,  but  is  allied  to  snake  poison.  It  is  generated  in  a 
wound  by  the  growth  of  the  tetanus  bacillus.  When  no  wound 
exists  it  is  believed  that  the  virus  may  gain  admission  by  absorp- 
tion through  the  unbroken  mucous  or  cutaneous  surface.  It  is 
only  quite  recently  that  an  absolutely  pure  culture  of  the  bacillus 
has  been  obtained  (Fig.  43).  The  bacillus  occurs  as  long  deli- 
cate threads  with  slightly  rounded  ends.  When  sporing,  these 
threads  break  up  into  short  rods  which  usually  develop  a  spore  at 
one  end,  giving  them  a  drum-stick  shape.  It  is  anaerobic,  and 
hence  rapidly  loses  its  virulence  on  exposure  to  air.     Its  special 


The  tetanus  bacillus.     X  i,ooo. 
(After  Sternberg.) 


1 66  GENERAL    PATHOLOGY    OF    INJURIES. 

habitat  would  appear  to  be  ordinary  earth,  thus  serving  to  explain 
the  frequency  of  tetanus  in  the  wounded  who  have  been  allowed 
to  lie  on  the  ground  after  battles.  It  has  been  found  in  the  sur- 
roundings of  horses,  the  floor  of  stables,  and  in  soil  taken  from 
beneath  the  floor  of  hospital  wards  in  which  cases  of  tetanus  have 
occurred.  The  bacillus  only  exists  in  the  soil  or  the  wound  ;  not 
in  the  blood  or  nervous  system. 

The  symptoms  usually  begin  by  a  feeling  of  stiffness  in  the  mus- 
cles of  the  neck  ;  the  patient  complains  that  he  is  unable  to  open 
his  mouth  widely  {trismus),  and  that  his  throat  feels  sore  on 
swallowing.  On  examination,  the  muscles  of  the  neck,  the  mas- 
seters,  and  perhaps  the  abdominal  muscles,  are  found  hard  and 
rigid,  and  the  face  presents  a  characteristic  expression  from  the 
angles  of  the  mouth  being  drawn  slightly  upwards  by  the  contrac- 
tion of  the  facial  muscles.  Later,  other  of  the  voluntary  muscles, 
e^jecially  those  of  respiration,  become  affected,  and  distinct  spasms 
attended  with  severe  pain  and  varying  in  duration,  occur  from 
time  to  time.  The  spasms  are  induced  by  the  slightest  irritation, 
a  breath  of  air,  the  least  noise,  the  merest  touch  ;  and  the  remis- 
sions become  shorter,  or  only  partial,  as  the  disease  is  fully  estab- 
lished. During  the  spasms  the  face  assumes  an  expression  of  in- 
tense anguish  {?isus  sardoiiici/s),  the  respirations  and  pulse  are 
quickened,  and  the  body  is  variously  contorted.  Thus,  when 
the  spinal  muscles  are  chiefly  affected  the  back  becomes  arched, 
so  that  in  severe  cases  the  patient  rests  only  on  his  head  and 
heals  {opisthotonos)  ;  more  rarely  the  body  is  bent  forward,  being 
rolled  upas  it  were  like  a  ball  {onprosthotonos)  ;  whilst  still  more 
rarely  it  may  be  drawn  to  one  or  other  side  {plcurosthotouos). 
The  skin  is  bathed  in  perspiration,  the  urine  concentrated  and 
high  colored,  and  the  bowels  obstinately  confined.  The  temper- 
ature may  remain  normal,  or  be  but  slightly  raised  ;  though  some- 
times shortly  before  death  it  runs  very  high,  and  has  been  known 
to  register  112°  Fahr.  'Jlie  patient  is  unable  to  sleep,  but  the 
intellect  continues  clear  to  the  end.  Death  may  occur  from 
spasm  of  the  glottis,  spasm  of  the  respiratory  muscles,  or  from 
exhaustion  or  syncope.  Recovery  hardly  ever  takes  place  when 
the  symptoms  are  acute,  but  if  the  ])atient  survive  till  the  twelfth 
day  the  prognosis  is  more  favorable,  and  becomes  more  and  more 
so  every  day. 

Diagnosis. — From  strychnine  jjoisoning  and  hydrophobia, 
tetanus  is  distinguished  by  the  spasms  being  of  a  tonic  instead  of 
a  clonic  character,  and  further  from  hydrophobia  by  the  absence 
of  hallucinations  and  the  discharge  of  viscid  saliva,  signs  which 
are  characteristic  of  that  affection. 

Treatment. — Hitherto  the  treatment  has  consisted  in  attempt- 
ing to  tide  the  patient  over  the  first  few  days,  in  the  hope  that  the 


TREATMENT  OF  TETANUS.  167 

affection  might  become  less  acute  and  gradually  wear  itself  out. 
Thus  little  or  nothing  could  be  done  beyond  supporting  the 
strength  with  fluid  nourishment,  administered  by  the  rectum,  if 
the  patient  is  unable  to  swallow,  and  preventing  the  spasms  as 
much  as  possible  by  the  most  absolute  quiet,  the  avoidance  of  all 
sources  of  irritation,  the  employment  of  such  sedatives  as  chloral 
or  opium,  and  relieving  the  constipation  by  purgatives  and  ene- 
mata.  Curara,  Indian  hemp.  Calabar  bean,  eserine,  and  numerous 
other  drugs  internally,  and  subcutaneous  injections  of  carbolic 
acid  (}■  of  a  grain),  paraldehyde,  pilocarpin  and  urethane,  have  all 
had  their  advocates,  and  cases  have  been  reported  in  which  suc- 
cess was  attributed  to  their  use.  The  treatment  of  tetanus,  how- 
ever, has  through  the  recent  researches  of  Behring,  Kitasato, 
Tizzoni,  Cantani,  Roux,  Vaillard,  and  others,  been  placed  on  a 
different  footing,  and  the  injection  of  the  tetanus  antitoxin,  with 
the  excision  of  the  wound,  although  success  has  not  yet  been  met 
with  in  any  case  that  might  not  possibly  have  otherwise  re- 
covered, may  be  looked  upon  as  the  only  rational  treatment.  It 
has  been  found  by  these  observers  that  the  blood  serum  of  ani- 
mals rendered  immune  to  tetanus  by  previous  injections  of  the 
tetanus-poison  i^tetano-toxin)  taken  from  a  wound  or  from  artificial 
cultures  of  the  bacilli,  possesses  the  power  when  injected  into 
another  animal  of  destroying  the  toxic  properties  of  the  tetano- 
toxin,  or  of  conferring  immunity  on  the  animal  even  though 
twenty  or  thirty  times  the  amount  sufficient  to  kill  be  injected. 
In  an  ordinary  case  of  tetanus,  however,  the  injection  of  the  an- 
titoxin is  not  sufficient,  in  that  fresh  doses  of  the  poison  are  con- 
tinually being  generated  by  the  bacilli  in  the  wound,  and  absorbed 
into  the  system.  On  the  earliest  signs  of  tetanus,  therefore,  the 
wound  should  be  freely  excised  or  amputation  performed  before 
the  antitoxin  treatment  is  begun.  The  antitoxin  which  is  ob- 
tained by  evaporating  the  serum  to  dryness  in  vacuo,  in  which 
state  it  can  be  kept  indefinitely,  should  be  dissolved  in  ten  times 
its  weight  of  pure  distilled  water,  and  injected  subcutaneously  into 
any  part  of  the  body,  preferably  the  abdominal  walls  or  the  inner 
part  of  the  thigh.  The  dose  will  depend  upon  the  severity  of  the 
case  and  the  period  of  the  disease  at  which  the  treatment  is  be- 
gun. For  a  case  of  moderate  severity,  it  is  recommended  to  use 
23^  grammes  as  a  first  injection  and  half  a  gramme  daily  for  the 
next  four  days.  In  a  severe  case,  and  in  one  in  which  treatment 
has  not  been  begun  until  some  days  after  the  symptoms  have  come 
on,  4^4  grammes  may  be  injected  at  once,  and  \-2,  gramme  to  i 
gramme  used  subsequently,  according  to  the  effect  of  a  first  dose. 
In  preparing  and  injecting  the  antitoxin,  care  must  be  taken  that 
it  does  not  come  into  contact  with  chemical  antiseptics  or  heat, 
since  both  impair  its  action. 


1 68  INJURIES    OF    SPECIAL    TISSUES. 


SECTION  III. 

INJURIES  OF  SPECIAL  TISSUES. 

INJURIES    OF    BONES. 

Fraciures. — A  fracture  may  be  defined  as  a  sudden  and  forcible 
solution  of  continuity  of  a  bone. 

The  Causes  of  fracture  are  predisposing  and  exciting,  i.  The 
predisposing  causes  may  be  enumerated  as  senile  atrojjhy,  fatty 
degeneration,  rickets,  mollities  ossium,  locomotor  ataxy,  tubercle, 
syphilitic  gummata,  caries  and  necrosis,  and  malignant  growths ; 
in  brief,  any  condition  rendering  the  bone  unusually  fragile,  to 
which  may  be  added  the  male  sex  as  more  frequently  exposing  to 
\iolence.  2.  The  exciting  causes  are  either  external  violence  or 
muscular  action,  {a)  External  violence  may  be  direct  or  indirect. 
In  fracture  from  di?-ect  violence,  the  bone  is  broken  at'  the  spot 
where  the  violence  is  applied.  Such  fractures  are;jsually  attended 
with  more  serious  consequences  than  fractures  from  indirect 
violence,  since  the  soft  parts  are,  as  a  rule,  much  injured,  and  the 
fragments  comminuted  or  fissured,  and,  perhaps,  driven  into  im- 
portant organs,  as  the  lung  in  fracture  of  the  ribs,  or  the  brain  in 
fracture  of  the  cranium,  etc.  In  indirect  violence,  the  fracture 
occurs  at  a  distance  from  the  spot  where  the  violence  is  applied, 
as,  for  instance,  a  fracture  of  the  clavicle  from  a  fall  on  the  arm. 
The  bone  usually  breaks  at  its  weakest  spot,  and  the  fracture  may 
be  rendered  compound,  from  the  fragments,  which  are  often  sharp 
and  irregular,  being  driven  through  the  soft  parts.  Fracture  from 
indirect  violence  is  most  common  in  the  bones  of  the  extremities 
and  the  base  of  the  skull.  (/^)  Muscular  action,  except  in  the 
case  of  the  patella,  is  not  a  common  cause  of  fracture.  When  the 
long  bones  are  broken  in  this  way,  they  are  usually  the  seat  of 
some  of  the  affections  mentioned  above  as  predisposing  causes. 
When  a  bone  infiltrated  with  a  malignant  growth,  or  softened  by 
mollities  ossium,  breaks  from  very  slight  violence,  the  fracture  is 
said  to  occur  spontaneously. 

Varieties  of  fracture. — A  fracture  is  said  to  be  simple  when  the 
skin  covering  it  is  not  broken  ;  compound  when  a  woimd  through 
the  skin  and  soft  parts  leads  down  to  the  seat  of  the  fracture. 
Whether  simple  or  compound,  fractures  are  further  spoken  of: — 
I.  According   to  their  extent,  as: — complete,  when  the  bone  is 


FRACTURES.  1 69 

broken  quite  across ;  incomplete  or  greemtick,  when  partially- 
broken  and  partially  bent ;  coinmimited,  when  broken  into  several 
pieces ;  and  multiple,  when  two  or  more  distinct  fractures  occur 
in  the  same  bone,  or  in  different  bones.  2.  According  to  the 
condition  of  the  fragments,  as  : — impacted,  when  one  fragment  is 
driven  into  another  ;  fissured,  when  there  is  a  mere  crack  through 
the  bone  without  displacement ;  depressed,  when  one  fragment  is 
pressed  in  below  the  surface,  as  in  some  fractures  of  the  cranium  ; 
punctured,  when  there  is  a  small  perforation  with  driving  inwards 
of  the  fragments ;  and  splintered,  when  only  a  fragment  of  bone 
is  chipped  off.  3.  According  to  the  line  of  fracture,  as  : — trans- 
verse, oblique,  spiral,  longitudinal,  or  stellate,  terms  which  suffi- 
ciently explain  themselves.  A  fracture,  moreover,  is  said  to  be 
complicated,  when  associated  with  other  injuries,  as  rupture  of  the 
main  artery  of  the  limb,  imphcation  of  a  large  joint,  etc. 

Displacement  of  the  fragments,  especially  in  the  bones  of  the 
limbs,  commonly  occurs,  except  the  fracture  is  transverse,  when, 
as  in  the  case  of  the  tibia,  there  may  be  little  or  none.  The 
causes  of  the  displacement  may  be  enumerated  as :  i.  The 
weight  of  the  limb  acting  on  the  lower  fragment ;  2.  Muscular 
contraction  ;  and  3.  The  violence  producing  the  fracture.  The 
amount  of  displacement  will  depend  in  part  on  the  direction  of 
the  line  of  fracture,  and  in  part  on  whether  the  periosteum  is  or 
is  not  torn.  Thus  the  displacement  is  usually  considerable  when 
the  fracture  is  obhque,  insignificant  when  transverse,  especially  if 
the  periosteum  is  intact.  The  displacement  is  spoken  of  as 
angular,  lateral,  longitudinal,  and  rotatory,  according  to  the 
direction  which  the  fragments  bear  to  each  other. 

Signs. — Before  examining  for  fracture,  the  clothes  should  be 
carefully  removed,  and  the  parts  handled  tenderly,  lest  a  simple 
fracture  be  converted  into  a  compound  by  a  sharp  fragment  being 
driven  through  the  skin.  Thus,  in  the  case  of  the  leg,  the  boot 
should  be  cut  off,  the  trousers  ripped  up  the  seam,  and  the  stock- 
ing split  with  scissors.  The  injured  side  should  always  be  com- 
pared with  the  sound  side.  The  general  signs  of  fracture  are  : — 
I.  Alteration  in  the  shape  of  the  part;  2.  Swelling;  3.  Loss  of 
function;  4.  Preternatural  mobility ;  5.  Shortening;  6.  Pain;  7. 
Crepitus  ;  8.  The  sensation  of  a  sudden  snap  or  giving  way  of  the 
bone  experienced  by  the  patient.  No  one  of  the  above  signs 
alone,  except  crepitus,  is  absolutely  diagnostic  of  fracture  ;  and 
crepitus  itself,  when  the  fragments  are  impacted,  may  be  absent, 
or  may  be  stimulated  by  joint-crepitus,  effusion  into  the  sheaths 
of  tendons,  emphysema,  and  by  the  grating  of  osteophytes  in 
chronic  osteo-arthritis.  True  crepitus,  however,  having  been 
once    felt,  can  hardly  afterwards  be  mistaken ;  it  is  readily  dis- 


lyo  INJURIES   OF   SPECIAL   TISSUES. 

tingiiished  from  false  crepitus  by  its  harsher  and  more  grating 
character.  The  shortening  may  be  natural  or  due  to  some  pre- 
vious injury  or  disease,  as  a  former  fracture,  osteo-arthritis,  etc. : 
shortening  also  occurs  in  dislocation.  Increased  mohinty  may  not 
be  present,  as  when  a  fracture  is  firmly  impacted.  Fain  may,  of 
course,  occur  from  causes  other  than  fracture  ;  it  may  often  be 
elicited  in  fracture  when  crepitus  cannot  be  obtained.  Swellivig, 
loss  of  function,  and  alteration  in  the  shape  of  the  part  may  be 
present  in  other  injuries,  but  are  useful  signs  in  some  forms  of 
fracture.  Too  much  weight,  it  need  hardly  be  said,  should  not 
be  given  to  the  patient's  sensations,  as  a  snap  or  feeling  of  the 
bone  giving  way  may  occur  in  rupture  of  a  tendon,  ligament,  etc. 

The  Diagnosis  is  often  difficult,  especially  : — i.  When  the  frac- 
ture is  near,  or  extends  into,  a  joint,  owing  to  effusion  of  blood  or 
synovial  fluid  into  the  joint-cavity.  2.  When  there  is  great  ex- 
travasation of  blood,  or  later,  effusion  of  inflammatory  products 
about  the  fragments.  3.  When  the  fracture  is  transverse,  and 
there  is  no  displacement,  especially  if  the  fragments  are  held  in 
position  by  a  companion  bone,  as  the  fibula  in  fracture  of  the 
tibia.  4.  When  the  fracture  is  subperiosteal.  In  the  cranium,  a 
simple  uncomplicated  fissured  fracture  cannot  be  diagnosed. 

How  to  obtain  crepitus. — Grasp  the  limb  firmly  above  and 
below  the  suspected  fracture,  and  when  there  is  shortening,  make 
extension  to  bring  the  rough  surfaces  into  contact.  Then  gently 
attempt  to  move  the  lower  on  the  upper  fragment.  Having  once 
assured  yourself  that  crepitus  is  present,  desist  from  your  manipu- 
lations, as  they  not  only  give  the  patient  pain,  but  injure  the  soft 
parts.  In  some  cases,  as  in  fracture  of  the  neck  of  the  femur, 
where  the  nature  of  the  injury  from  the  presence  of  other  signs  is 
quite  obvious,  crepitus  should  not  be  sought  lest  an  impacted 
fracture  be  rendered  non-impacted  and  afterwards  remain  un- 
united, or  the  periosteum  uniting  the  fragments  be  torn,  and  a 
like  result  ensue. 

The  Method  of  Union  is  similar  to  that  which  occurs  in  the 
healing  of  a  wound  of  the  soft  parts  by  the  first  intention.  P>lood 
is  at  first  extravasated  between  and  around  the  fragments  (Fig. 
44).  Then  quickly  follows  a  simple  traumatic  inflammation; 
the  periosteum  and  adjacent  soft  tissues,  together  with  the 
medulla,  become  infiltrated  with  leucocytes,  which  have  escaped 
from  the  vessels  of  the  inflamed  periosteum,  medulla,  and  bone, 
and  by  proliferating  tissue  cells  derived  from  these  parts.  The 
inflammation  subsides  in  a  few  days,  leaving  the  fragments  em- 
bedded in  a  mass  of  soft,  red,  gelatinous  material  {granulation- 
tissue),  derived  chiefly  from  the  leucocytes  and  proliferated 
tissue  cells,  but  according  to  some  observers   in  part   from  the 


FRACTURES. 


171 


remains  of  the  extravasated  blood  that  has  not  been  absorbed. 
This  granulation-tissue,  which  is  called  callus,  consists  here,  as  in 
the  union  of  soft  parts,  of  small  round  cells  with  a  small  amount 
of  firm  intercellular  substance,  and  delicate  loops  of  capillaries, 
which  are  derived  in  part  from  the  vessels  in  the  Haversian 
canals,  and  in  part  from  the  vessels  in  the  periosteum,  and  ad- 


P"lG.  44. 


Fig.  45. 


Diagram  of  the  fragments  a  few  hours  after 
simple  fracture.  The  periosteum  is  torn 
and  ragged,  and  separated  from  the  bone 
for  a  slight  distance  above  and  below  the 
fracture.  Blood  is  extravasated  between 
the  fragments,  in  the  medullary  canal,  and 
in  the  periosteum  and  other  soft  tissues 
surrounding  the  fracture. 


Diagram  of  the  process  of  repair  in  simple 
fracture.  A.  Ensheathing  callus;  B.  In- 
ternal callu.s;  c.  Permanent  callus.  Com- 
mencing ossification  of  the  ensheathing 
callus  is  indicated  by  the  darker  shading  at 
the  angle  between  the  periosteum  and  the 
bone. 


jacent  soft  tissues.  It  is  found  (i)  replacing  the  periosteum,  and 
extending  for  some  distance  around  the  bone,  above  and  below 
the  hne  of  fracture,  forming  a  spindle-shaped  tumor,  by  which 
the  ends  of  the  fragments  are  surrounded,  as  it  were,  with  a  fer- 
rule {ensheaihing  callus,  Fig.  45,  a)  ;  (2)  replacing  the  medulla 
for  some  little  distance  up  and  down  the  medullary  canal  {internal 
callus,  Fig.  45,  b)  ;  and  later  (3)  between  the  ends  of  the  frag- 
ments {pertnanent  inlermediate  o?-  definite  callus.  Fig.  45,  c).  The 
ensheathing  callus  and  internal  callus  are  gradually  organized  into 
fibrous  tissue,  becoming  harder  and  firmer,  and  in  animals,  and,  in 
some  instances,  in  children,  are  converted  into  cartilage,  or  fibro- 
cartilage.  The  outermost  layers  of  the  fibrous  tissue  into  which 
the  ensheathing  callus  is  thus  converted  form  a  new  periosteum. 
Ossification  of  the  ensheathing  callus  now  begins — generally  in 
the  angle  between  the  periosteum  and  the  bone,  and  proceeds 
along  the  surface  of  the  bone,  where  it  is  preceded  by  the  forma- 
tion of  cells  like  osteoblasts,  and  also  along  the  surface  of  the  en- 
sheathing callus  beneath  the  new  periosteum,  till  the  upper  and 
lower  layers  of  ossifying  callus  meet  opposite  the  line  of  fracture. 


172 


INJURIES   OF   SPECIAL   TISSUES. 


Ossification  of  the  internal  callus  goes  on  at  the  same  time.  Per- 
manent callus,  as  soon  as  the  ends  of  the  bone  are  thus  fixed  by 
the  ensheathing  and  internal  callus,  is  formed  between  the  ends 
of  the  fragments,  and  later  also  undergoes  ossification.  It  is 
probably  derived  (i)  from  leucocytes  which  have  escaped  from 
the  vessels  in  the  enlarged  Haversian  canals  of  the  inflamed  and 
softened  ends  of  the  fragments,  and  (2)  from 
a  proliferation  of  the  cells  of  the  connective 
tissue  lining  these  parts.  The  ensheathing 
callus  and  internal  callus  having  discharged 
their  functions,  are  gradually  absorbed. 

Where  the  ends  of  the  fragments  overlap, 
the  ensheathing  callus  fills  up  the  angles 
(Fig.  46)  :  and  while  the  open  end  of  the 
medullary  canal  in  each  fragment  is  thus 
closed,  its  continuity  through  the  bone  is  re- 
stored by  the  absorption  of  the  intervening 
walls  of  the  contiguous  and  overlapping  frag- 
ments (Fig.  46).  When  the  fragments  are 
in  good  apposition,  and  are  kept  at  rest,  little 
or  no  ensheathing  callus  is  formed;  but  when 
there  is  much  displacement,  or  rest  is  im- 
possible, as  in  a  fractured  rib,  or  difficult  to 
obtain,  as  in  a  fractured  clavicle,  a  consider- 
able amount  is  produced.  In  children,  even 
when  the  parts  are  kept  at  rest  and  in  good 
apposition,  the  formation  of  much  ensheath- 
ing callus  is  the  rule. 

Treatment. — Here  only  the  indications  for 
treatment  will  be  pointed  out.  The  particular 
methods  will  be  given  under  Special  Fractures. 
A.  Treatment  of  simple  fracture. — The  in- 
dications are — (i)  to  reduce  the  fracture, 
that  is,  to  place  the  fragments  in  apposition,  so  as  to  restore  as 
far  as  possible  the  bone  to  its  normal  shape;  (2)  to  keep  it  in 
this  position  by  properly  applied  apparatus  till  firm  union  has 
occurred  ;  (3)  to  promote  the  restoration  of  the  normal  functions 
of  the  part;  and  (4)  to  attend  in  the  meanwhile  to  the  general 
health  and  comfort  of  the  patient. 

I.  'Ihe  reduction,  or  as  it  is  popularly  called  the  setting  of  the 
fracture,  should  not  l)e  undertaken  until  the  apparatus  into  which 
the  limb  is  to  be  permanently  jjlaced  is  ready  ;  but  the  fragments 
should  be  temporarily  fixed,  so  as  to  jirevent  further  injury,  such 
as  a  sharp  fragment  being  forced  tiirough  the  skin.  Thus,  in  the 
case  of  the  lower  extremity,  the  injured  limb  may  be  bound  to  the 


Fracture  of  the  femur 
with  overlapping  frag- 
ments to  show  round- 
ing off  of  angles,  and 
restoration  of  medullary 
canal  by  absorption  of 
intervening  bone  (St. 
Bartholemew's  Hospi- 
tal Museum).  - 


TREATMENT   OF    FRACTURES.  1 73 

sound  one,  or  secured  by  a  handkerchief  to  an  impromptu  splint, 
such  as  an  umbrella  or  walking-stick  :  or  if  the  patient  is  not  seen 
till  he  is  already  in  bed,  the  limb  may  be  placed  between  sand- 
bags or  wrapped  in  a  pillow.  As  a  general  rule  the  fracture  should 
be  reduced  as  soon  as  possible  ;  but  where  there  is  much  swelling 
the  part  may  remain  wrapped  in  a  pillow  or  secured  by  sand-bags 
till  the  swelling  has  subsided.  When  the  fracture  is  transverse, 
the  fragments  will,  as  a  rule,  be  but  slightly  displaced,  and  little 
as  regards  reduction  will  be  required.  In  other  instances,  as 
when  the  line  of  fracture  is  obhque,  considerable  trouble  in  bring- 
ing the  fragments  into  apposition  may  be  experienced.  The 
chief  obstacles  to  be  overcome  are  (i)  the  contraction  of  the 
muscles,  which  are  thrown  into  action  by  the  irritation  of  the 
fragments  ;  and  (2)  the  impaction  of  the  fragments,  or  the  inter- 
position of  muscle  or  tendon  between  them.  The  splint  or  other 
apparatus  being  in  readiness,  extension  in  the  case  of  fracture  of 
a  limb  should  be  made  on  the  lower  fragment,  preferably,  as  a 
rule,  through  the  intervention  of  the  joint  below.  Thus,  in 
fracture  of  the  fore-arm  or  leg,  extension  should  be  made  from 
the  hand  or  foot  respectively,  whilst  counter-extension  is  applied 
at  the  same  time  to  the  upper  fragment,  also  preferably  through 
the  joint  above.  Whilst  steady  traction  is  thus  being  made,  the 
Surgeon  should  gently  manipulate  the  fragments,  and  he  should 
not  rest  satisfied  till  the  symmetry  of  the  part  has  been  as  far  as 
possible  restored,  and  the  limb  is  found,  both  on  inspection  and 
measurement,  to  correspond  as  near  as  may  be  with  the  opposite 
side.  In  this  position  the  parts  should  be  held  till  the  apparatus 
for  permanently  fixing  them  has  been  applied.  Where  great  diffi- 
culty is  experienced  in  reducing  the  fracture  owing  to  muscular 
spasm,  the  limb  should  be  flexed  or  placed  in  such  a  position  as 
will  tend  to  relax  the  opposing  muscles,  or  if  this  does  not  suffice 
an  anaesthetic  may  be  administered.  At  times  the  subcutaneous 
division  of  a  tendon  may  become  necessary  before  the  fracture 
can  be  reduced.  In  some  impacted  fractures,  as  of  the  neck  of  the 
humerus  or  femur,  it  may  be  advisable  not  to  disturb  the  frag- 
ments, as  by  so  doing  non-union,  a  worse  condition  than  impac- 
tion, may  result.  The  special  methods  of  reduction  which  may 
be  required  for  certain  fractures  will  be  given  under  Varieties  of 
Fracture. 

2.  To  keep  the  fragments  in  apposition  till  union  has  taken 
place,  numerous  contrivances  have  been  invented.  They  may  be 
said  to  consist  of  splints,  cradles,  fracture-boxes,  bandages  hard- 
ened by  plaster  of  Paris,  silica,  paraffin,  glue,  or  gum  and  chalk, 
and  such  material  as  gutta-percha,  poroplastic  felt,  and  leather, 
moulded  to  the  individual  case.     In  oblique  fractures,  where  the 


T74  INJURIES   OF   SPECIAL   TISSUES. 

ends  of  the  bone  cannot  be  retained  completely  in  apposition, 
Lane  advises  that  an  incision  should  be  made  down  to  the  bone 
and  the  fragments  secured  by  wiring. 

The  method  of  applxing  splints  will  be  better  learnt  by  three 
months'  dressing  in  the  wards  than  by  any  verbal  description. 
The  points  that  should  be  chiefly  attended  to  are  :  i.  The  splints 
should  be  well  paddeii.  2.  Pressure  should  not  be  made  over 
points  of  bone.  3.  Strappmg  or  bandages  should  not  be  put  on 
too  tightly.  4.  Circular  constriction  of  the  limb  should  be 
avoided.  5.  The  splints  where  possible  should  reach  beyond 
both  the  joint  above  and  the  joint  below  the  fracture.  6.  The 
fracture  should  not,  as  a  rule,  be  covered  with  the  bandage.  7. 
The  patient  should  be  seen  within  twenty-four  hours  after  the 
splints  have  been  applied,  as  swelling  of  the  part  is  apt  to  occur, 
and  the  bandages  thus  become  too  tight.  8.  The  part  having 
once  been  properly  secured  in  splints,  should  not  needlessly  be 
disturbed.  9.  Should  the  fragments  become  displaced  from 
spasm  of  the  muscles,  steady  extension  as  by  a  stirrup,  weight, 
and  pulley,  will  usually  overcome  the  difficulty.  10.  The  part 
below  the  fracture  may  sometimes  be  bandaged  with  advantage 
to  prevent  oedema. 

The  time  the  splints  should  be  kept  on  varies  greatly,  and  will 
be  stated  under  each  individual  fracture.  On  their  removal  the 
limb  should  be  kept  at  rest  for  some  time  longer  in  a  plaster  of 
Paris,  gum  and  chalk,  or  other  form  of  stiff  bandage,  till  complete 
consolidation  has  taken  place.  At  some  hospitals  the  fracture,  if 
not  severe,  is  placed  at  once  in  a  plaster  of  Paris  bandage  or 
plaster  of  Paris  splints  {Bavarian  splints^.  If  this  or  other 
similar  material  is  used,  the  limb  should  be  well  padded  with 
cotton-wool,  the  toes  or  fingers  left  exposed,  the  joints  above  and 
below  included  in  the  bandage,  and  the  limb  subsequently  raised. 
The  patient  should  be  visited  a  few  hours  after  the  plaster  of 
Paris  has  been  applied,  so  that  should  the  circulation  have  become 
impeded  from  swelling  of  the  limb,  the  plaster  bandage  may  be 
removed  before  any  serious  damage  has  had  time  to  ensue.  The 
indications  for  at  once  removing,  or  for  loosening  the  band- 
age by  cutting  it  in  places  are  :  i,  much  pain;  2,  swelling;  3, 
numbness  ;  and  4,  signs  of  obstructed  circulation  in  the  fingers  or 
toes.  A  tight  bandage,  it  should  be  remembered,  is  more  dan- 
gerous in  the  upper  than  in  the  lower  limb,  because  in  the  former 
most  of  the  venous  return  is  by  the  superficial  veins.  Should  the 
bandage  become  loose,  it  must  of  course  be  removed  and  re- 
applied. 

3.  To  promote  the  restoration  of  the  normal  functions  of  the 
part  physiological  after-treatment  is  required.     Thus  it  will  often 


UNUNITED    FRACTURE. 


175 


Fig.  47. 


be  found  after  the  apparatus  is  finally  removed,  especially  if  the 
fracture  is  near  a  joint,  that  the  joint  is  stiff,  the  tendons  are  more 
or  less  glued  together,  and  the  muscles  wasted  and  atrophied. 
Under  these  circumstances  shampooing,  massage,  electricity, 
friction  with  stimulating  liniments,  and  passive  movements  of  the 
joint,  should  be  sedulously  employed. 

4.  The  general  health  and  comfort  of  the  patient 'iYi.ovXdi  not  be 
neglected.  Thus  if  he  is  confined  to  bed,  boards  should  be  sub- 
stituted for  the  ordinary  webbing  or  steel  laths  of  the  bedstead ; 
the  sheets  should  be  kept  smooth  ;  and  bed-sores  guarded  against 
by  the  use  of  water-cushions  and  by  hardening  the  skin  over 
prominent  points  of  bone  with  spirit  lotions.  Old  people  should 
not  be  kept  too  long  in  bed,  lest  ])assive  congestions  of  the  lungs 
occur.  The  general  health  should  be  promoted  by  attention  to 
the  secretions,  regulation  of  the  diet,  and  administration  of  seda- 
tives to  relieve  pain  and  promote  sleep. 

Ununited  fracture  and  false  joint. — An  ununited  fracture  is 
one  in  which  the  fragments  are  either  totally  ununited,  or  merely 
bound  together  by  fibrous  tissue. 
Some  fractures,  such  as  transverse 
fractures  of  the  patella,  and  fractures 
extending  into  joints  in  general,  sel- 
dom or  never  unite  by  bone,  but 
remain  merely  bound  together  by 
fibrous  tissue  ;  but  as  fibrous  union 
here  appears  to  be  the  normal 
method  of  repair,  they  are  not,  as  a 
rale,  spoken  of  as  ununited  fractures. 

The  condition  of  the  fragments  in 
an  ununited  fracture  varies.  The 
fragments  may  be  completely  sepa- 
rated, with  the  ends  rounded  off 
and  the  medullary  canal  closed  ;  or 
they  may  be  bound  together  by  long 
pliable  bands  of  fibrous  tissue  per- 
mitting of  considerable  movement,  or 
by  tough  fibrous  bands  allowing  of 
but  very  little,  or  by  a  fibro-cartila- 
ginous  material — a  kind  of  ensheath- 
ing  callus.  The  last  condition,  how- 
ever, is  thought  by  some  to  be  merely 
an  example  of  delayed  union,  and  not  one  of  permanent  ununited 
fracture. 

h.  false  Joint  or  pseudarthrosis  is  merely  a  variety  of  ununited 
fracture  in  which  the  ends  of  the  fragments  are  rounded  off  and 


False  joint  followins  fracture  of 
the  humerus.  St.  Bartholomew's 
Hospital  Museum.) 


176  INJURIES   OF   SPECIAL   TISSUES. 

eburnated,  or  covered  with  a  layer  of  fibrous  tissue  or  fibro-car- 
tilage,  and  enclosed  in  a  strong  fibrous  capsule  formed  by  the 
condensation  of  the  surrounding  soft  tissues  (Fig.  47).  A  fluid 
resembling  synovia  has  occasionally  been  found  within  the  capsule. 
A  false  joint  may  resemble  a  hinge  or  a  ball-and-socket  joint. 
The  latter  condition  is  more  common  in  fractures  near  the  articu- 
lar ends  of  bones  where  rotatory  as  well  as  angular  movement 
may  occur ;  the  former  in  fractures  through  the  shafts  of  bones 
where  angular  movement  only  is  permitted. 

The  Causes  are  local  and  constitutional.  The  local  dat:  i. 
The  fragments  not  having  been  kept  thoroughly  at  rest ;  2.  The 
fragments  not  having  been  placed  in  apposition  in  consequence 
of  {a)  muscular  contraction;  {b)  the  loss  of  a  large  piece  of 
bone,  as  in  compound  fracture ;  (r)  the  intervention  of  a  piece  of 
muscle,  tendon,  or  periosteum,  or  a  foreign  body,  as  a  portion  of 
clothes,  between  the  fragments  ;  and  {d)  the  effusion  of  synovial 
fluid  in  the  case  of  a  fracture  into  a  joint ;  3.  The  necrosis  at  the 
end  of  one  of  the  fragments ;  4.  The  interference  with  the 
arterial  supply  of  one  of  the  fragments,  as  from  injury  of  the 
medullary  artery:  and  5,  The  poor  supply  of  blood  to  one  of 
the  fragments,  as  in  fracture  of  the  anatomical  neck  of  the  hu- 
merus. 

Constitutional  causes. — Syphilis,  tubercle,  gout,  Bright's  dis- 
ease, fevers,  scurvy,  the  cancerous  cachexia,  pregnancy,  locomotor 
ataxy,  old  age,  alteration  of  the  patient's  habits,  the  sudden  depri- 
vation of  stimulants,  are  all  said  to  be  causes  of  ununited  fracture. 
No  doubt  any  condition  that  lowers  the  vitality  and  consequent 
power  of  repair  of  the  tissues  has  a  tendency  to  delay  union,  but 
it  seems  doubtful  if  any  of  the  above  conditions  except  scurvy  is, 
in  itself,  apart  from  the  local  causes,  sufficient  to  prevent  the  bone 
uniting.  In  paralysis  agitans  the  difficulty  of  keeping  the  patient 
quiet,  and  hence  the  almost  complete  impossibility  of  immobiliz- 
ing the  fragments  by  splints,  etc.,  may  be  regarded  as  a  cause  of 
non-union. 

Sometimes  the  callus,  after  having  been  formed,  appears  to  be 
re-absorbed,  the  fracture  being  then  spoken  of  as  disunited.  'J'his 
appears  to  be  not  uncommon  in  scurvy. 

Treatment. — Constitutional  as  well  as  local  treatment  may  be 
required.  In  recent  casee — /.  e.,  where  the  fracture  is  found  un- 
united after  having  been  kept  in  splints  for  the  usual  time,  a  con- 
dition sometimes  called  delayed  union  in  contradistinction  to 
ununited  fracture,  the  sjjlints  should  be  re-applied,  and  in  such  a 
manner  as  to  insure  perfect  immobility  of  the  fragments  ;  whilst 
the  general  health  should  be  improved  by  every  means  in  our 
power ;  and  any  constitutional  taint,  as  syphilis,  gout,  etc.,  that  may 


UNUNITED    FRACTURE.  1 77 

be  detected,  combated  by  appropriate  remedies.  If  tlie  patient 
has  been  accustomed  to  stimulants,  and  has  been  deprived  of 
them,  he  should  be  allowed  a  moderate  quantity.  In  some  cases 
it  may  be  expedient  to  put  the  fracture  in  an  immovable  appa- 
ratus, and  let  the  patient  get  about  on  crutches.  Should  union 
still  not  occur,  the  ends  of  the  fragments  should  be  rubbed 
together  to  excite  some  amount  of  inflammation,  and  sphnts 
or  other  apparatus  be  again  applied.  This  failing,  and  in  long- 
standing cases,  two  courses  are  open ;  either  to  try  to  unite 
the  fragments  by  some  operative  procedure,  or  to  apply  some 
form  of  permanent  apparatus  to  fix  them  in  position.  The 
choice  of  these  methods  will  depend  upon  the  situation  of  the 
fracture,  whether  it  is  of  the  nature  of  an  ununited  fracture 
or  a  false  joint ;  and  upon  the  patient's  age,  constitutional  con- 
dition, occupation,  and  rank  of  life.  Thus  in  the  case  of  an 
ununited  fracture  of  the  upper  third  of  the  femur  in  a  patient  of 
advanced  age  or  of  broken  constitution,  an  operation  is  attended 
with  great  risk  to  life,  and  for  such,  some  form  of  apparatus  is 
better  suited.  But  when  the  patient  is  young  or  of  good  consti- 
tution, or  his  occupation  is  such  that  he  cannot  afford  an  appara- 
tus and  the  continual  expense  of  keeping  it  in  good  order, 
and  especially  where  the  fracture  is  in  the  shaft  of  the  hu- 
merus, an  operation  should  be  undertaken.  Such  operations 
may  be  divided  into  three  classes,  according  as  they  have  for 
their  object  i,  the  setting  up  of  inflammation  about  the  ends 
of  the  fragments,  or  in  the  fibrous  tissue  uniting  them,  and  so  in- 
ducing ossification  ;  2,  the  fixation  of  the  fragments  by  wire  or 
other  forms  of  suture,  by  ivory  cylinders,  bone  ferrules,  etc.,  and 
3,  the  cutting  out  of  the  false  joint,  and  bringing  the  refreshed 
surfaces  of  the  bone  into  apposition,  and  keeping  them  there  till 
union  has  occurred.  Among  the  first,  which  are  applicable  to  an 
ununited  fracture  rather  than  to  a  false  joint,  may  be  mentioned 
—  {a)  the  subcutaneous  scraping  of  the  ends  of  the  fragments; 
{b)  passing  a  seton  between  them  ;  and  (c)  cutting  dow^n  upon 
and  inserting  ivory  pegs  into  the  fragments  in  order  to  induce 
ossification.  Of  these  the  subcutaneous  method  is,  perhaps,  at- 
tended with  the  least  risk,  but  cases  to  which  it  is  applicable  are 
the  exception.  The  passage  of  a  seton  is  highly  dangerous,  and 
should  never  be  employed.  The  insertion  of  ivory  pegs  for  the 
purpose  of  inducing  ossification  is  not  reliable.  Under  the  second 
method — namely,  that  of  direct  fixation  of  the  fragments,  are  in- 
cluded {a)  suturing  the  fragments;  {b)  the  introduction  of 
ivory  cyhnders  into  the  medullary  canal ;  and  (r)  fixation  by 
bone  ferrules,  {a)  Suturing,  as  formerly  done,  allowed  of 
lateral  and  longitudinal  displacement  if  the  fracture  was  oblique'. 


178 


INJURIES    OF    SPECIAL    TISSUES. 


Wille,  therefore,  advises  that  in  oblique  fractures,  two  grooves 
(Fig.  48)  be  cut  with  a  saw  in  the  fragments,  the  direction  of  the 

grooves  being  at  a  right 
Fic;-  4S.  angle    to    the    fractured 

surfaces,  and  the  frag- 
ments tied  together  with 
wire.  Further,  where 
both  the  fragments  can 
be  drilled  vertically,  he 
draws  with  a   book,  in- 

Method  of  wiring  the  fragments  in  oblique  fractures.  Veilted    lOr    thC     purpOSC 

(Fig.  49),  the  wire 
through  the  drill  holes,  divides  it,  and  twists  each  half  together 
(Fig.  50).     ((5)  The  insertion  of  ivory  cylinders,  or,  better,  of  hol- 


FlG.  49. 


Fig.  50. 


Wille's  method  of  wiling  the  fragments  in  oblique  fractures. 

low  cylinders  of  bone,  into  the  medullary  cavity,  is  successful  in 
fixing  the  fracture  and  preventing  lateral  and  longitudinal  dis- 
placement where  the  fracture  is  not  oblique,     (c)   Fixation  with 

bone  ferrules   (Fig.  51)    is 
'■'"'■•  SI-  advised  by  Senn.     For  the 

femur  and  humerus  he  em- 
ploys the  femur  of  the  ox 
(Fig.  51A)  ;  for  the  tibia, 
the  tibia  of  the  ox  (Fig. 
51K)  The  ferrule  should 
be  a  quarter-of-an  inch  to 
an  inch  in  breadth,  the 
medullary  canal  being  en- 
larged by  a  round  file  till  the  ferrule  does  not  exceed  one-sixth 
of  an  inch  in  thickness.  When  an  inch  broad  it  should  be 
perforated  as  shown  in  Fig.  51c,  so  as  to  facilitate  its  absorption 
after  the  fracture  has  united.  If  desired  it  may  be  partially  or 
completely  decalcified.  If  the  ferrule  is  too  large  the  space 
between  it  and  the  fragments  may  be  packed  with  small  splinters- 


Scnn's  bone  ferrules  for  fixing  the  fragments  in  un- 
united fractures.     (After  Senn.) 


UNUNITED   FRACTURE. 


179 


Senn's  bone  ferrules  for  fixing  the  fragments  in  ununited 
fractures  in  situ.     (After  Senn.) 


Fig.  53. 


Fig.  54. 


of  bone.     The  position  of  the  ferrules  when  m  situ  is  shown  in 
Fig.    ^2.      The    thb-d 

•  Fig   c:2 

method,  or  operation 
for  cutting  out  a  false 
joint,  consists  in  mak- 
ing an  incision  down 
to  the  bone,  chiseling 
or  sawing  away  ob- 
liquely the  ends  of  the 
fragments,  and  then 
fixing  them  in  one  of 
the  ways  above-men- 
tioned. 

Recently  in  unu- 
nited fractures  with 
loss  of  substance  from 
necrosis,  the  gap  has 
been  filled  by  grafting 
a  piece  of  iDone  be- 
tween the  fragments. 
The  grafts  may  be  ob- 
tained from  a  young 
animal,  or  from  a  limb 
immediately  after  am- 
putation. In  one  suc- 
cessful case,  wedge- 
shaped  pieces  of  bone 
removed  in  osteotomy 
of  the  tibia  were  used. 
Whilst  being  trans- 
ferred the  grafts 
should  be  kept  at  a 
temperature  of  100°  in 
a  capsule  of  boiled  salt 
solution  (3j  to  Oj). 

Malunited  frac- 
ture OR  VICIOUS  UNION. 

—  I.  Fractures  incon- 
sequence of  having 
been  improperly  set  or 
not  kept  at  rest  in 
good  position,  may 
unit^at  an  angle  (Fig. 
53),  or  in  some  othtr 
faulty  direction.     2.  If  splints  have  been  removed  too  early,  or 


Malunited  fracture.  (St.  Bar- 
tholomew's Hospital  Mu- 
seum.) 


Vicious  union  after  frac- 
ture. (St.  Bartholo- 
mew's Hospital  Mu- 
seum.) 


l8o  INJURIES   OF   SPECIAL   TISSUES. 

if  in  the  case  of  the  lower  extremity  the  patient  has  been  allowed 
to  walk  too  soon,  the  callus  may  yield,  and  deformity  result.  3. 
Two  adjacent  bones,  as  the  radius  and  ulna  in  the  fore-arm,  may 
become  united  to  each  other  by  callus  (Fig.  54).  4.  A  greenstick 
fracture  from  neglect  to  straighten  the  partially  bent  bone  before 
applying  splints  may  consolidate  in  its  distorted  condition. 

Treatment. — If  the  fracture  is  recent,  and  the  fragments  are  not 
firmly  united,  the  patient  should  be  placed  under  an  anaesthetic, 
the  faulty  position  rectified,  and  splints  properly  applied.  If  firm 
union  has  already  occurred,  an  attempt  should  be  made  to  re- 
fracture  the  bone,  under  an  anaesthetic,  with  the  hands  ;  if  this 
fails,  and  in  long-standing  cases,  osteoclasia  by  means  of  Grattan's 
or  Thomas's  instrument  should  be  undertaken,  or  subcutaneous 
osteotomy  may  be  performed,  or  in  some  instances  a  wedge- 
shaped  piece  of  bone  removed.  A  sharp  fragment  projecting 
beneath  the  skin  may  sometimes  be  sawn  off  with  advantage, 
though  it  should  be  remembered  that  such  projections  often  be- 
come rounded  off  with  time. 

Separation  of  epiphyses. — This  injury  may  be  regarded  as  a 
variety  of  fracture.  It  consists  in  the  forcible  wrenching  of  the 
epiphysis  from  the  shaft  at  their  cartilaginous  line  of  union,  and 
consequently  can  only  occur  in  subjects  under  twenty-one  years 
of  age,  the  period  at  which  nearly  all  of  the  epiphyses  have  united 
with  the  diaphyses.  The  injury  is  most  common  in  the  upper  and 
lower  ends  of  the  humerus,  and,  from  the  proximity  of  the 
epiphyseal  lines  to  the  shoulder  and  elbow-joints  respectively,  is 
liable  to  be  mistaken  for  a  dislocation  Repair  usually  takes 
place  by  osseous  tissue  ;  hence  the  bone  ceases  to  grow  at  the  in- 
jured end,  and  permanent  shortening  of  the  limb  if  the  patient 
has  not  completed  his  growth  will  then  result.  For  treatment, 
see  Special  Fractures  a?ui  Dislocations. 

A  COMPOUND  FRACTURE  is  ouc  in  which  there  is  a  wound  through 
the  skin  and  other  soft  tissues  leading  to  the  fracture. 

Cause. — The  wound  may  be  produced,  i.  At  the  same  time  as 
the  fracture,  either  by  the  violence  directly  tearing  open  the  soft 
tissues,  or,  as  is  more  usually  the  case,  by  one  of  the  fragments 
being  forced  through  the  skin  either  by  the  original  violence  or 
by  muscular  contraction.  2.  Subsequently  to  the  fracture,  by  the 
patient  trying  to  rise  or  to  use  the  injured  limb;  or  by  want  of 
care  in  removing  the  clothes,  in  handling  the  fracture,  or  trying 
for  crepitus.  3.  Still  later,  by  ulceration  or  sloughing  of  the  soft 
parts,  due  to  inflammation  set  up  through  failure  to  render  and 
keep  the  injury  aseptic,  and  the  laceration  of  the  tissues  or  the 
pressure  of  a  projecting  fragment. 

State  of  the  parts, — 'Ihere  may  be  a  mere  puncture,  with  but 


COMPOUND   FRACTURE. 


Fig.  55. 


lus;  B.  Internal  callus; 
c.  Necrosed  fragments ; 
D.  Granulations  lining 
wound  leading  to  fracture. 
(After  Billroth.) 


little  if  any  more  injury  to  the  soft  tissues  than  may  be  met  with 

in  simple  fracture  ;  or  with  or  without  a  large  external  wound  of 

the  skin  there  may  be  extensive  laceration 

of  the  soft  tissues,  protrusion  of  one  or  other 

fragment,    extensive     comminution     of    the 

bone,  implication  of  a  large  joint,  rupture  of 

the  main  artery,  vein  or  nerve,  and  in  ex 

treme  cases  crushing   and  laceration  of  the 

whole  of  the  injured  part  of  the  limb. 

Union  of  compound  fractin-e. — When  the 
wound  is  small,  and  has  been  closed  at  once, 
and  the  soft  parts  are  but  little  injured,  the 
process  of  repair  is  as  a  rule  similar  to  that 
of  a  simple  fracture.  When  the  wound  is 
large,  or  there  is  much  laceration  of  the  soft 
tissues  or  comminution  of  the  bone,  suppura-  Diagram  showing  process 
tion  is  very  likely  to  ensue,  and  union  is  then      ?<"  separation  of  necrosed 

.  ,     ,  ^  -^    ,      .  .        .  -  ,  bone   m   compound   Irac- 

erfected  by  granulations  springing  from  the  ture.  a.  Ensheathing  cai 
ends  of  the  fragments  and  periosteum,  the 
process  being  analogous  to  union  of  the  soft 
parts  by  the  second  intention.  The  granu- 
lations either  undergo  direct  ossification,  or 
first  pass  through  a  fibrous,  or  in  some  instances  a  cartilaginous 
stage.  The  loose  fragments  and  injured  tissues,  where  the  bone 
is  comminuted  and  the  soft  parts  are  much  bruised  or  lacerated, 
are  cast  off  by  the  process  of  ulceration  (Fig.  55)  before  healing 
ensues.  Where,  however,  a  fragment  retains  its  connection  with 
the  periosteum,  it  may  not  lose  its  vitality,  but  may  help  in  the 
restoration  of  the  bone.  Where  a  large  portion  of  bone  is  de- 
nuded of  periosteum  it  generally  dies,  and  is  usually  separated  as 
in  the  ordinary  process  of  necrosis  (Fig.  55).  It  may,  however, 
become  embedded  in  the  new  bone,  and  remain  a  source  of  irri- 
tation for  years. 

Dangers  of  compound  fracture. —  i.  Immediate  dangers  :  shock 
and  collapse  from  loss  of  blood,  which  may  prove  fatal  in  a  few 
hours  ;  more  rarely  fat-embolism.  2.  Intermediate  dangers  ;  septic 
inflammation,  erysipelas,  saprcemia,  septicaemia,  pyaemia  and 
tetanus.  3.  Late  dangers :  hectic,  lardaceous  disease,  and  ex- 
haustion from  long-continued  suppuration. 

The  treatment  varies  according  to  the  state  of  the  parts,  the  age 
and  heaUh  of  the  patient,  and  the  situation  of  the  fracture.  Our 
aim,  when  possible,  should  be  to  convert  a  compound  into  a 
simple  fracture.  Thus,  when  the  wound  is  small,  a  mere  puncture, 
it  should,  after  being  well  cleansed  by  antiseptics,  be  closed  by  a 
piece  of  antiseptic  gauze,  and  the  case  treated  as  a  simple  frac- 


l82  INJURIES   OF   SPECIAL   TISSUES. 

tore.  When  the  wound  is  large  and  lacerated,  or  other  serious 
injury  of  the  bone,  soft  parts,  or  neighboring  joint  has  been  sus- 
tained, the  question  of  amputation  will  arise.  (See  below,  Ain- 
piitaiion  in  Compound  Fracture.^  Having,  however,  deter- 
mined to  save  the  hmb,  the  indications  are — (i)  to  reduce  the 
fracture,  and  maintain  the  fragments  at  perfect  rest,  and  (2)  to 
promote  the  healthy  heahng  of  the  wound.  The  fracture  should 
be  set  as  described  under  simple  fracture ;  if  the  fragments  pro- 
trude they  should  be  reduced  where  practicable,  sawn  off  where 
not,  enlarging  the  wound  in  the  skin  if  necessary,  but  taking  care 
not  to  remove  more  bone  than  is  sufficient  to  accomplish  the  object. 
Splinters  when  attached  by  periosteum  should  not  be  removed, 
but  simply  placed  in  position  and  then  secured,  under  some  cir- 
cumstances, by  sutures.  If  it  is  found  difficult  to  keep  the  frag- 
ments in  place,  they  may  be  fixed  in  position  by  wiring  or  by 
Senn's  bone-ferrules  (page  177).  The  wound  should  be  rendered 
aseptic  by  washing  out  all  corners  with  some  antiseptic  fluid. 
When  this  can  be  thoroughly  done,  the  soft  tissues-muscles, 
tendons  and  fascise — should  be  united  by  catgut  sutures  and  the 
wound  closed  ;  but  when  there  is  much  laceration,  and  thorough 
cleansing  cannot  be  effectually  carried  out,  the  wound  should  be 
kept  freely  drained  to  prevent  the  decomposition  of  any  extra- 
vasated  blood  and  discharges.  The  limb  should  then  be  secured 
in  some  form  of  apparatus,  so  arranged  that  the  wound  is  not 
covered  by  it,  but  is  freely  accessible  for  dressing  without  dis- 
turbing the  fragments.  If  the  patient's  general  condition  remains 
good,  and  he  has  no  pain  or  discomfort,  the  dressings  may  be  left 
undisturbed  till  the  wound  has  healed  ;  but  should  suppuration 
occur,  a  careful  inspection  ought  to  be  made  daily  to  see  that  the 
drainage  is  efficient ;  and  if  any  collection  of  pus,  which  is  apt  to 
form  in  the  intermuscular  planes,  be  discovered,  it  should  be  let 
out  with  antiseptic  precautions  and  the  wound  drained.  Any 
portions  of  bone  that  may  necrose  should  be  removed  as  soon  as 
loose.  When  the  wound  has  healed,  the  fracture  should  be 
treated  in  the  same  way  as  a  simple  one.  Any  complications,  as 
erysipelas,  saprsemia,  etc.,  that  may  occur  must  be  treated  as  de- 
scribed in  other  parts  of  the  book.  The  constitutional  treatment 
is  the  same  as  that  indicated  in  other  severe  injuries.  (See  also 
Simple  Fracture.) 

Question  0/  amputation  in  compound  fracture. — In  slight  and  un- 
complicated cases,  and  in  those  severe  injuries  in  which  the  hmb 
is  completely  shattered,  the  course  to  be  pursued  is  quite  clear  ;  in 
the  one  case  to  spare  the  limb,  and  in  the  other  to  amputate  im- 
mediately, liut  in  other  instances  the  question  of  attempting  to 
save  versus  amputate  becomes  one  of  the  most  serious  and  anxious 


COMPLICATIONS   OF   FRACIXTRE.  1 83 

that  the  surgeon  has  to  decide.  It  was  formerly  taught  that  we 
should  amputate — i.  If  there  is  great  laceration  of  the  soft  parts 
and  extensive  loss  of  skin.  2.  If  there  is  much  comminution  of 
the  bone.  3.  If  the  main  artery  or  nerves  of  the  limb  are  torn. 
4.  If  a  large  joint  is  implicated.  5.  If  the  limb  is  likely  to  be  of 
little  subsequent  service  from  the  severity  of  the  injury ;  and  6.  If 
the  patient  is  old  or  his  constitution  broken  down.  No  one  of 
these  signs  is  in  itself  in  every  case  a  sufficient  reason  for  ampu- 
tating ;  and  when  we  can  succeed  in  rendering  the  wound  com- 
pletely aseptic  some  of  them,  as  comminution  of  the  bone, 
implication  of  a  large  joint,  and  the  advanced  age  of  the  patient, 
can  hardly  be  now  ever  considered  as  a  justification  for  so  severe 
a  measure.  The  main  considerations  are  :  Can  the  wound  be 
rendered  aseptic,  and,  if  so,  is  the  arterial  supply  sufficient  to 
prevent  gangrene  ;  is  the  condition  of  the  nerves  such  that  the  hnib 
will  not  be  hopelessly  paralyzed ;  and  is  the  laceration  of  the 
muscles  and  tendons  within  such  liinits  as  will  allow  of  a  useful 
limb  ?  If  these  questions  can  be  answered  in  the  affirmative  an 
attempt  should  be  made  to  save  the  limb  ;  if  in  the  negative  amputa- 
tion should  be  done.  The  indications  for  amputation  are  of 
course  more  imperative  if  the  fracture  involves  the  lower  extremity, 
especially  the  femur ;  but  each  case  must  be  judged  on  its  own 
merits,  and  some  surgeons  will  attempt  to  save  what  others  con- 
demn. Every  legitimate  effort  should  of  course  be  made  to  save 
a  limb,  but  we  must  remember  that  in  attempting  to  do  so  we 
may  place  the  patient's  life  in  danger,  and  that  too  often  it  is  a 
question  of  a  hmb  versus  the  life. 

If  amputation  is  not  performed  at  once  or  within  the  first 
twenty-four  hours,  and  it  then  becomes  evident  that  the  limb  m_ust 
be  sacrificed,  the  amputation  should  not  as  a  rule  be  undertaken 
till  the  traumatic  fever  has  subsided,  the  surgeon  watching  care- 
fully for  the  most  favorable  opportunity  that  presents  itself.  The 
signs  calling  for  amputation  during  the  suppurating  stage  are  : — 
Extensive  suppuration,  great  sloughing  of  the  soft  tissues,  inflam- 
mation and  suppuration  of  a  neighboring  joint,  necrosis  of  large 
portions  of  bone,  exhaustion,  hectic  and  lardaceous  disease. 

Complications  of  fracture. — A  simple  fracture  may  be  com- 
plicated by  any  of  the  geiieral  affections  attending  other  injuries, 
as  shock,  traumatic  delirium,  tetanus,  retention  of  urine;  and  by 
such  local  conditions  as,  i,  concomitant  dislocation;  2,  extravasa- 
tion of  blood  ;  3,  rupture  of  the  main  artery,  vein,  or  nerve  ;  4,  im- 
plication of  a  joint ;  5,  gangrene  from  tight  bandaging  ;  6,  paralysis 
from  the  use  of  a  crutch,  or  the  implication  of  a  nerve  in  the 
callus  ;  7,  venous  thrombosis  ;  8,  embolism  ;  9,  formation  of  ulcers 
or  bed-sores  over  prominences  of  bone;  10,  erysipelas;  11,  fat- 


184  INJURIES   OF   SPECIAL   TISSUES. 

embolism  ;  and  12,  suppuration  where  there  is  much  laceration  of 
the  tissues  with  giving  way  of  the  skin,  the  fracture  then  becoming 
compound. 

A  cotnpound fracture  may  in  consequence  of  the  open  wound  be 
complicated,  in  addition  to  the  above-mentioned  affections,  by 
septicinflammation'AVL^siippuratioJi,  nccrosis,saprcemia,septicccmia, 
pycemia,  hectic  and  tetanus. 

Of  these  complications  of  fracture,  whether  simple  or  compound, 
the  only  ones  that  need  be  further  mentioned  here  are  the  follow- 
ing :— 

Fracture  combiiied  tvith  dislocation. — In  simple  fracture  the 
treatment  consists  in  placing  where  possible  the  fracture  in  splints, 
and  then  attempting  the  reduction  of  the  dislocation.  Where  the 
dislocated  end  cannot  be  replaced  the  fragments  must  be  allowed 
to  consolidate,  and  another  attempt  then  made  to  reduce  the  dis- 
location ;  or  the  surgeon  may  try  to  manipulate  the  dislocated 
portion  into  its  socket,  and  then  apply  splints  to  the  fracture.  In 
compound  fracture  this  complication  is  a  much  more  serious  one, 
especially  when  it  occurs  in  the  lower  extremity,  and  involves  one 
of  the  larger  joints.  In  the  knee,  ankle,  and  wrist,  amputation, 
and  in  the  elbow  and  shoulder,  excision,  is  usually  indicated.  In 
the  smaller  joints  the  dislocation  may  be  reduced,  and  the  case 
treated  as  a  wounded  joint  complicated  by  fracture. 

Fracture  implicatiiii^  a  Joint. — A  simple  fracture  extending  into 
a  joint  is  not  an  uncommon  accident ;  indeed  the  elbow-  and 
knee-joints  are  always  involved  in  fracture  of  the  olecranon  and 
patella  respectively,  and  the  shoulder  and  hip-joint  in  the  intra- 
capsular fracture  of  the  neck  of  the  humerus  and  femur.  The  in- 
jured joint  may  become  stiff  or  ankylosed,  though  usually  no 
serious  mischief  ensues.  Suppuration  is  very  rare.  The  limb  in 
putting  up  the  fracture  should  be  placed,  except  in  the  case  of 
fracture  of  the  olecranon,  in  a  position  in  which  it  will  be  of  most 
service  should  bony  ankylosis  ensue.  Inflammation  and  stiffness 
of  the  joint  from  fibrous  adhesions  should  be  treated  in  the 
way  described  under  Diseases  of  Joints.  A  compound  fracture 
extending  into  a  joint,  though  more  serious,  does  not  necessarily 
call  for  amputation  or  excision,  and  may  be  treated  in  the  way  de- 
scribed under  Wounds  of  Joints,  liut  should  such  be  required, 
excision  in  the  upper  extremity  and  amputation  in  the  lower  may 
be  said  with  certain  reservations  to  be  the  rule  of  practice.  If  an 
operation  is  considered  unnecessary  the  case  should  be  treated 
as  a  wounded  joint,  and  splints  according  to  the  variety  of  fracture 
applied. 

Fat-embolism  is  a  rare  complication  of  fracture,  but  is  more 
frequent  in  the  comijound  than  in  the  simple  variety,  and  in  bones 


COMPLICATIONS    OF   FRACTURE.  1 85 

that  have  undergone  atrophy.  It  appears  that  in  consequence  of 
the  crushing  of  the  medulla,  fat-globules  gain  admission  into  the 
veins,  and  become  lodged  in  the  capillaries  of  the  lungs,  brain, 
kidneys,  and  other  organs.  It  is  attended  by  dyspnoea,  either 
cyanosis  or  pallor,  collapse,  irregular  action  of  the  heart,  and  at 
times  by  coma  and  death.  Venesection,  injection  of  ether  into 
the  veins,  and  artificial  respiration,  have  been  suggested  in  way 
of  treatment. 

Crutch  palsy  is  due  to  the  pressure  of  a  crutch  on  the  musculo- 
spiral  nerve.  It  is  best  avoided  by  well  padding  the  crutches,  or 
by  having  handles  to  the  crutches  so  that  part  of  the  weight  falls 
on  the  hands.  An  ingenious  crutch  with  handles  has  lately  been 
introduced.  The  paralysis,  which  chiefly  affects  the  extensor 
muscles  of  the  fore-arm,  giving  rise  to  dropped  wrist,  usually 
passes  off  when  the  crutch  is  no  longer  used.  Should  it  not  do  so, 
electricity  and  massage  may  be  employed. 

Paralysis  or  neuralgia  sometimes  occurs  in  consequence  of  the 
implication  of  a  nerve  in  the  callus.  An  operation  is  then  at 
times  necessary  to  liberate  the  nerve. 

Gangrene  from  tight  bandaging  is  occasionally  met  with,  and  is 
of  the  moist  variety.  All  bandages  should  of  course  be  at  once 
removed,  in  the  hope  that  the  limb  may  recover.  When  the  gan- 
grene is  thoroughly  established,  amputation  above  the  seat  of 
fracture,  and  of  course  well  beyond  the  gangrene,  must  be  per- 
formed. Short  of  gangrene,  the  partial  cutting-off  of  the  blood- 
supply  may  cause  inflammation  and  degeneration  of  the  muscles, 
followed  by  stubborn  contracture  {ischcemic  rigidity). 

Extravasatio7i  of  blood  into  the  tissues  is  not  uncommon  in 
simple  fracture,  owing  to  the  tearing  of  some  of  the  smaller  blood- 
vessels by  one  of  the  rough  fragments.  The  extravasated  blood 
causes  in  some  instances  considerable  swelling,  and  on  making 
its  way  to  the  surface  gives  the  part  a  bruised  and  black  appear- 
ance, and  frequently  causes  the  cuticle  over  it  to  be  raised  into 
blebs.  These  blebs  differ  from  those  formed  in  gangrene  in  that 
they  are  fixed  and  firm,  whilst  the  latter  are  movable  over  the 
moist  and  slippery  skin  beneath.  No  special  treatment  is  re- 
quired, the  blebs  should  not  be  opened,  and  the  blood  will  grad- 
ually be  absorbed.    In  rare  instances,  however,  suppuration  ensues. 

Rupture  of  the  main  artery  or  vein  occasionally  occurs,  causing 
when  the  skin  is  unbroken  a  tense  swelling  at  the  seat  of  fracture, 
attended  in  the  case  of  the  artery  by  coldness  of  the  limb,  and 
cessation  of  the  pulse  in  the  arteries  below.  In  compound  frac- 
ture, rupture  of  the  artery  is,  as  a  rule,  easily  diagnosed,  in  that 
pressure  on  the  artery  above  the  fracture  stops  the  bleeding. 
Treatment. — Should  the  swelling  in  simple  fracture  increase  in 


l86  INJURIES   OF   SPECIAL   TISSUES. 

spite  of  elevation  of  the  limb,  cold,  and  pressure  on  the  main 
artery  above,  and  gangrene  threaten,  three  courses  are  open  :  i, 
ligature  of  the  artery  above  ;  2,  tying  the  artery  at  the  seat  of  frac- 
ture ;  or  3,  amputation.  In  the  lower  limb  amputation  is  probably, 
as  a  rule,  the  safest  course  ;  in  the  upper  limb  ligature  of  the  ves- 
sel at  the  seat  of  fracture  may  be  attempted.  But  the  conditions 
that  call  for  the  adoption  of  one  or  other  of  these  methods  are 
too  various  to  discuss  here.  In  compound  fracture  the  vessel 
should  be  tied  in  the  wound  if  possible.  If  not,  amputation  will 
probably,  though  not  invariably,  be  the  right  course. 

INJURIES   OF   JOINTS. 

Contusions  of  joints  may  be  produced  by  any  mechanical  vio- 
lence. They  are  generally  attended  with  pain  and  stiffness  on 
movement,  and,  in  severe  cases,  with  swelling  from  effusion  of 
blood  {h(^marthf'osis),  and  later,  of  serous  fluid  (sy?ioviiis)  into 
the  synovial  cavity.  If  the  contusion  is  neglected,  especially  in 
tuberculous  children,  acute  or  chronic  inflammatory  changes  may 
ensue,  leading  to  destruction  of  the  joint.  The  treatment  consists 
in  placing  the  part  at  rest  on  a  splint,  or  in  a  plaster-of-Paris 
bandage,  and  applying  cold  by  means  of  an  ice-bag  or  Leiter's 
tubes.  Where  there  is  much  effusion  into  the  synovial  cavity,  and 
consequently  considerable  tension  and  pain,  aspiration  of  the 
joint  may  be  advantageously  practiced,  and  pressure  afterwards 
applied. 

Sprains. — A  sprain  is  a  stretching  or  partial  rupture  of  the  liga- 
ments of  a  joint  without  separation  of  the  articular  surfaces. 
Sprains  are  generally  due  to  a  violent  wrench  or  twist  of  the  joint, 
and  are  often  accompanied  by  laceration  of  the  tendons  and 
other  soft  tissues  around.  They  are  of  most  frequent  occurrence 
in  the  ankle,  shoulder,  wrist,  and  knee. 

Sig7is  and  dia^^nosis. — Severe  pain,  often  localized  to  certain 
points,  and  increased  on  movement,  inability  to  bear  weight  on 
the  limb,  swelling  and  ecchymosis  from  effusion  of  blood  in  and 
around  the  joint,  and  later  inflammatory  effusion  into  the  synovial 
cavity.  The  absence  of  signs  of  fracture  or  of  discoloration  will 
usually  suffice  to  distinguish  a  sprain  from  one  or  other  of  these 
injuries  ;  but  where  there  is  much  swelling  it  may  be  difficult  or 
impossible  to  make  a  diagnosis  till  the  swelling  has  subsided.  If 
there  is  any  doubt,  the  injury  should  be  treated  as  a  fracture. 

The  consequences  of  a  neglected  sprain  may  be  very  serious, 
especially  in  rheumatic  and  gouty  subjects.  Thus,  as  the  result 
of  the  incomplete  absorption  of  the  inflammatory  products,  the 
.imperfect  repair  of  the  torn  ligaments,  the  formation  of  .fibrous 


DISLOCATIONS.  187 

adhesions  in  and  around  the  joint,  and  the  gluing  of  the  surround- 
ing tendons  to  their  sheaths,  a  sprain  may  be  followed  by  long- 
continued  pain,  stiffness,  weakness  and  even  fibrous  ankylosis  of 
the  joint.  At  times  in  tuberculous  subjects  a  sprain  may  be  the 
starting-point  of  destructive  joint-disease. 

Treatme7it. — The  indications  are  to  place  the  joint  at  perfect 
rest  till  the  torn  ligaments  have  had  time  to  heal ;  to  prevent  or 
subdue  inflammation  ;  and,  should  stiffness  or  ankylosis  have  en- 
sued, to  restore  the  mobility  of  the  joint  by  breaking  down  any 
adhesions  that  may  have  formed.  Thus,  if  seen  at  once,  a  plaster- 
of- Paris  or  a  Martin's  bandage  should  be  put  on ;  or  if  much 
sweUing  has  already  occurred,  the  parts  should  be  placed  on  a 
splint  or  in  a  sling,  and  either  cold  in  the  form  of  lead-lotion  or 
ice,  or  heat  in  the  form  of  hot  fomentations,  apphed.  For  very 
slight  cases,  however,  a  few  days'  rest  with  the  part  supported  by 
a  wet  bandage,  followed  by  the  use  of  a  stimulating  linament,  is 
all  that  is  usually  necessary.  The  joint  in  any  case  should  not  be 
kept  too  long  at  rest  lest  stiffness  ensue  ;  but  as  soon  as  all  signs 
of  inflammation  have  disappeared,  passive  movements  should  at 
once  be  begun.  If  stiffness  or  fibrous  ankylosis  has  already  oc- 
curred, friction,  shampooing,  and  massage  may  be  tried  ;  or  the 
joint  may  be  forcibly  wrenched  under  an  ansesthetic,  provided  all 
signs  of  active  inflammation  have  ceased. 

Dislocations. — A  dislocation  is  the  forcible  separation  of  the 
articular  end  of  a  bone  from  the  part  with  which  it  is  naturally  in 
contact. 

Varieties. — Dislocations  may  be  divided  into  the  Congenital 
and  the  Acquired ;  the  latter  again  into  the  Spontaneous  and  the 
Traumatic.  The  Spontaneous  are  those  that  occur  as  the  result 
of  disease  of  the  joints,  and  are  treated  of  elsewhere  (see  Diseases 
of  yoints).  The  Traumatic,  or  accidental  disclocations,  with 
which  we  are  here  specially  concerned,  are  spoken  of  as  com- 
pound or  simple  according  as  they  are,  or  are  not,  complicated 
with  an  external  wound  leading  into  the  joint ;  and  in  either  case 
as  complete  ox  partial  according  as  the  articular  surfaces  are,  or 
are  not,  completely  separated  from  each  other. 

The  causes  of  dislocation  are  predisposing  and  exciting.  The 
predisposing  causes  may  be  enumerated  as  :  i,  weakness  of  the 
ligaments  surrounding  the  joint  from  previous  dislocation  or 
disease ;  2,  the  shape  of  the  joint — ball-and-socket  joints  from 
their  extensive  range  of  movement  being  more  easily  dislocated 
than  hinge  joints  ;  3,  middle-life — the  bones  being  then  strong 
and  capable  of  resisting  fracture  and  the  muscles  powerful ;  4, 
the  male  sex — men  being  more  continually  exposed  to  violence 
than  women.     77ie  exciting  causes  are  usually,  i,  external  violence,. 


1 88  INJURIES   OF   SPECIAL   TISSUES. 

either  direct  or  indirect,  and  sometimes,  2,  muscular  action. 
Examples  of  each  will  be  met  with  in  the  section  on  special  dis- 
locations. 

The  Signs  common  to  all  dislocations  are  :  i.  Alteration  in  the 
shape  of  the  joint.  2.  Inability  to  move  the  limb  on  the  part  of 
the  patient,  and  more  or  less  fixidity  to  the  efforts  of  the  Surgeon. 
3.  An  alteration  in  the  relations  of  points  of  bone  about  the 
joint,  4.  An  abnormal  position  of  the  end  of  the  displaced  bone  ; 
and  5.  Shortening  or  lengthening  of  the  limb,  or  an  alteration  in 
its  axis.  The  signs  are  frequently  obscured  by  swelling  in  and 
about  the  joint,  due  to  extravasation  of  blood  or  effusion  of 
synovial  fluid.  Hence  the  importance  of  accurately  ascertaining 
the  nature  of  the  injury  immediately  after  the  accident,  as  when 
swelling  has  supervened  it  may  not  be  possible  to  make  a  diag- 
nosis till  it  has  subsided. 

The  state  of  the  parts  will  be  more  especially  referred  to  under 
each  special  dislocation.  Here  it  may  be  briefly  stated  that  the 
head  of  the  bone  is  generally  forced  through  the  capsular  liga- 
ment ;  whilst  other  of  the  ligaments,  surrounding  tendons,  and 
muscles,  may  be  ruptured  or  tightly  stretched,  and  the  arteries 
and  nerves  displaced,  pressed  upon,  or  torn.  In  the  ball-and- 
socket  joints  the  end  of  the  bone  will  be  found  either  opposite  the 
rent  in  the  capsule,  or  drawn  to  some  distance  from  it  by  muscu- 
lar contraction.  If  reduction  is  effected  early,  the  damaged 
ligaments  and  muscles  are  soon  repaired ;  but  they  remain  for 
some  time  weakened  and  stretched,  and  thus  predispose  to  re- 
dislocation.  Hence  the  importance  of  keeping  the  parts  at  rest 
until  firm  union  of  the  ruptured  capsular  and  other  ligaments  has 
occurred.  After  reduction  a  moderate  amount  of  inflammation 
and  serous  effusion  in  and  about  the  joint  generally  ensues,  but 
usually  subsides  in  a  few  days  if  the  parts  are  kept  at  rest,  the 
joint  becoming  gradually  restored  to  its  normal  condition.  If 
rest  is  neglected,  however,  the  rent  in  the  capsule  may  not  heal, 
but  remain  as  a  permanent  hole  with  smooth  edges,  allowing  the 
head  of  the  bone  to  slip  in  and  out  of  its  socket.  In  some  in- 
stances, moreover,  the  inflammation  may  run  into  suppuration, 
which  may  be  followed  by  ankylosis  of  the  joint. 

The  impediments  to  reduction  are : — In  recent  cases : — i.  The 
spasmodic  contraction  of  the  muscles  surrounding  the  joint.  2. 
The  small  size  of  the  rent  in  the  capsule.  3.  The  hitching  of 
points  of  bone  on  each  other  ;  and  4.  The  interposition  of  liga- 
ments, tendons  or  muscles.  In  old-standing  cases :  i .  The  forma- 
tion of  adhesions  around  the  displaced  bone.  2.  The  closure  of 
the  rent  in  the  capsule.  3.  The  permanent  shortening  of  the 
ligaments  and  muscles ;  and  4.  The  altefatioft  in  the  shape  of  the 


DISLOCATIONS.  l8g 

articular  surfaces,  in  part  from  absorption  and  in  part  from  the 
formation  of  new  bone.  The  contraction  of  the  muscles  generally 
increases  from  the  time  of  the  accident ;  hence  every  hour  the 
dislocation  remains  unreduced  the  more  difficult  the  reduction 
becomes. 

T/ie  conseqiiences  of  ?ion-reductioji  are  either  the  formation  of 
a  new  joint,  or  ankylosis,  the  former  being  more  common  in  ball- 
and-socket  joints,  the  latter  in  hinge  joints.  V/hen  any  move- 
ment between  the  dislocated  bones  exists,  the  osseous  surface  on 
which  the  displaced  bone  rests  is  converted  into  a  new  articular 
cavity  by  a  process  of  absorption  of  the  old  bone,  and  the  forma- 
tion of  new  bone  around  ;  the  end  of  the  displaced  bone  becomes 
adapted  by  a  similar  process  of  absorption  to  its  new  socket ;  and 
the  soft  tissues  around  become  condensed  so  as  to  form  a  kind  of 
new  capsule.  The  old  socket  in  the  meantime  becomes  more  or 
less  obliterated,  its  articular  cartilage  absorbed,  and  its  cavity 
filled  up  with  fibrous  tissue  or  new  bone.  The  range  of  move- 
ment in  the  newly-formed  joint  will  at  first  be  limited,  but  in  the 
course  of  time  under  appropriate  treatment  will  become  much 
more  free,  and  a  very  fairly  useful  limb  may  be  obtained.  When 
on  the  other  hand  the  dislocated  bone  is  immovably  fixed  upon 
another,  the  articular  cartilage  is  absorbed,  the  contiguous  osseous 
surfaces  unite,  and  bony  ankylosis  is  said  to  ensue.  The  muscles, 
moreover,  from  want  of  use,  undergo  shortening  or  partial  atrophy 
and  fatty  degeneration,  leaving  the  limb  in  a  more  or  less 
shrunken  and  wasted  condition. 

Treatment. — The  indications  are  :  i .  To  replace  the  articular 
surfaces  in  contact ;  and  2.  To  keep  them  there  until  the  rent  in 
the  capsule  has  united  and  the  torn  ligaments  and  muscles  have 
had  time  to  heal.  Unless  the  case  is  seen  immediately  after  the 
accident,  whilst  the  patient  is  faint,  and  the  muscles  are  in  con- 
sequence relaxed,  an  anaesthetic  had  better  be  given  to  overcome 
the  resistance  of  the  muscles.  The  reduction  may  then  be  ef- 
fected either  by,  i,  manipulation,  or  2,  extension. 

I.  Manipulation  consists  in  putting  the  limb  through  certain 
movements  of  flexion,  extension,  rotation,  and  circumduction, 
varying  according  to  the  situation  and  variety  of  the  dislocation. 
By  means  of  these  movements  we  endeavor : — («)  To  overcome 
the  obstacles  to  reduction  by  relaxing  the  stretched  ligaments  and 
tendons,  and  disengaging  any  hitching  points  of  bone  ;  and  (/5) 
To  make  the  displaced  head  retrace  as  it  were  its  steps,  and  re- 
enter its  socket.  In  order  to  employ  manipulation  successfully  it 
is  essential  that  the  Surgeon  should  know  the  anatomy  of  the  part, 
the  direction  in  which  the  bone  has  traveled  to  reach  its  abnormal 
situation,  and  the  probable  position  of  the  rent  in  the  capsule.    . 


190  INJURIES    OF    SPECIAL   TISSUES. 

2.  Extension  is  a  much  less  scientific  method  of  reducing  a  dis- 
location, and  should  never  be  resorted  to,  except  in  certain  forms 
of  dislocation  which  will  be  mentioned  hereafter,  till  manipulation 
has  been  tried.  It  was  the  method  almost  always  employed  bv 
the  older  Surgeons,  and  has  for  its  object  the  forcible  dragging  of 
the  displaced  end  of  the  bone  into  its  socket,  or  opposite  its 
socket,  into  which  it  is  then  drawn  by  muscular  contraction.  In 
many  forms  of  dislocation  the  method  is  as  harmful  in  practice  as 
it  IS  wrong  in  principle,  since  the  displaced  head,  as  in  some 
forms  of  dislocation  of  the  hip,  can  only  be  drawn  into  its  socket 
in  this  forcible  manner  by  rupturing  the  resisting  ligaments  and 
tendons.  In  employing  extension,  traction  is  made  in  the  long 
axis  of  the  limb  by  the  Surgeon,  either  with  his  hands  or  by 
means  of  a  jack-towel  secured  by  a  clove  hitch  to  the  limb,  or  if 
more  force  is  required,  by  multiplying  pulleys.  Counter-extension 
is  in  the  meanwhile  made  in  the  opposite  direction  to  the  extend- 
ing force,  but  in  the  same  straight  line,  either  by  the  surgeon 
pressing  with  his  heel  or  knee  on  the  part  above  the  dislocation, 
or  by  fixing  the  part  with  a  jack-towel  or  suitable  strap  to  a  hook 
in  the  floor  or  wall.  When  sufficient  extension  has  been  employed 
to  draw  the  head  of  the  bone  opposite  its  socket,  the  Surgeon 
should  endeavor  to  guide  it  into  its  place.  Before  the  introduc- 
tion of  chloroform  this  was  usually  effected  by  the  contraction  of 
the  muscles  themselves,  after  the  head  had  been  drawn  down  by 
the  extending  force. 

In  old-standing  cases,  before  either  manipulation  or  extension 
is  employed,  the  adhesions,  which  offer  the  chief  obstacle  to  re- 
duction, should  be  first  broken  down  by  cautiously  rotating  or 
circumducting  the  limb.  When  the  rent  in  the  capsule  has 
united,  the  old  socket  been  filled  up,  and  a  new  joint  formed,  re- 
duction is  of  course  physically  impossible;  but  even  then  the 
breaking  down  of  the  adhesions  may  greatly  improve  the  range 
of  motion  and  consequent  usefulness  of  the  limb.  In  attempting 
the  reduction  of  a  long-standing  dislocation,  however,  great  care 
must  be  exercised,  or  irreparable  damage  may  be  done.  Rather 
than  use  any  great  violence,  it  is  in  some  cases  better  at  once  to 
cut  down  upon  the  dislocation  and  divide  any  bands  which  may 
be  found  preventing  reduction.  Not  only  may  the  accidents  be- 
low enumerated  be  thus  avoided,  but  reduction  may  be  safely 
accomplished  at  later  periods  than  was  formerly  possible,  and 
with  antiseptic  treatment  of  the  wound  there  is  but  little  risk,  and 
good  movement  of  the  joint  may  be  expected. 

Among  the  accidents  that  hane  attended  violent  efforts  at  reduc- 
tion may  be  mentioned  : — i.  Rupture  of  the  main  artery,  vein  or 
nerves.     2.  Laceration  of  muscles  and  tendons.     3.  Tearing  open 


CONGENITAL   DISLOCATIONS.  I9I 

the  skin  and  soft  tissues,  thus  rendering  the  dislocation  compound. 
4.  Fracture  of  the  bone.  5.  Inflammation  and  suppuration  of 
the  joint  and  surrounding  parts  ;  and  6.  The  evulsion  of  the  limb. 

How  long  after  a  dislocation  may  an  attempt  he  made  at  rediic- 
tion  ? — Sir  Astley  Cooper  gave  the  time  at  between  three  and  four 
months  ;  but  since  the  introduction  of  chloroform  successful  cases 
have  been  reported  after  much  longer  periods.  In  an  old- 
standing  case  the  circumstances  which  should  influence  us  in  de- 
ciding whether  an  attempt  at  reduction  should  be  made  are  : — 
the  age  of  the  patient,  the  situation  of  the  dislocation,  the  presence 
or  absence  of  pain,  and  the  amount  of  usefulness  of  the  limb. 
By  the  new  method  of  open  division  of  the  adhesions  about  the 
joint,  the  time  at  which  a  dislocation  can  be  reduced  is  consider- 
ably extended.  This  method,  however,  should  not  be  employed 
unless  the  movements  of  the  joint  are  much  restricted,  and  the 
usefulness  of  the  limb  in  consequence  is  impaired. 

The  afte7'  treatment  consists  in  maintaining  the  part  at  rest  by 
suitably-applied  strapping  and  bandages,  and  in  preventing  or 
subduing  inflammation  by  cold,  evaporating  lotions,  etc.  The 
part,  however,  should  not  be  kept  at  absolute  rest  longer  than  is 
sufficient  for  the  torn  hgaments  and  other  soft  tissues  to  heal,  lest 
adhesions  form  and  stiffness  of  the  joint  ensue.  Passive  move- 
ments, therefore,  should  be  cautiously  begun  after  a  few  weeks ; 
and  friction,  shampooing,  or  galvanism  subsequently  employed  to 
restore  the  tone  of  the  wasted  muscles.  Where  stiffness  has  oc- 
curred the  adhesions  should  be  broken  down  under  an  anaesthetic, 
provided  there  are  no  signs  of  active  inflammation  in  the  joint. 

Treatment  of  compound  dislocations. — The  dislocation  should 
be  reduced,  the  parts  placed  at  perfect  rest,  and  the  case  treated 
as  a  wound  of  the  joint  (see  Wonnds  of  Joints).  In  consequence 
of  the  extensive  laceration  of  the  ligaments  and  other  soft  tissues, 
reduction  is  usually  quite  easy.  When  a  compound  dislocation 
is  combined  with  a  fracture  of  the  bone,  and  there  is  much  lacer- 
ation of  the  soft  parts,  amputation  of  the  limb  in  the  lower  ex- 
tremity, and  resection  of  the  joint  in  the  upper,  will  probably  be 
required. 

Congenital  dislocations  are  those  that  occur  during  intra- 
uterine life,  and  generally  depend  upon  some  malformation  of  the 
articular  surfaces,  rather  than  upon  actual  displacement  of  an 
originally  normal  articulation.  They  are  all  very  rare,  the  so- 
called  "congenital  dislocation"  of  the  hip,  however,  being  the 
least  so.  Little  or  nothing,  as  a  rule,  can  be  done  in  the  way  of 
treatment.  But  continuous  extension  in  the  horizontal  position 
with  pressure  over  the  trochanter  has  in  the  case  of  the  hip  been 
attended  with  considerable  success.     During  the  last  few  years 


192  INJURIES   OF   SPECIAL   TISSUES. 

several  operations  have  been  practised  for  congenital  dislocation 
of  the  hip  by  Lorenz,  Hoffa,  Ogston,  and  others.  Briefly,  these 
operations  consist  in  the  division  of  contracted  muscles  and  liga- 
ments, the  gouging  out  of  a  new  acetabulum  in  the  ilium,  and  in 
the  replacement  of  the  remains  of  the  head  of  the  femur  in  the 
new  socket  thus  formed. 

Wounds  of  joints.  A  joint  may  be  merely  punctured,  or  it 
may  be  laid  freely  upon.  The  wound  may  be  of  an  incised, 
lacerated  or  contused  character,  and  complicated  by  extensive 
injury  of  the  surrounding  soft  tissues,  or  by  dislocation  or  frac- 
ture of  the  articular  ends  of  the  bones.  In  the  latter  case  the 
wound  may  be  further  complicated  by  the  protrusion  of  the  dis- 
located bones  or  the  ends  of  the  fragments. 

A  wound  of  a  large  joint  should  always  be  regarded  as  serious, 
as  owing  to  the  difficulty  of  securing  an  efficient  drain,  and  of 
preventing  decomposition  of  the  extravasated  blood  and  serous 
secretion  in  the  synovial  pouches,  septic  or  infective  inflamma- 
tion is  very  liable  to  be  set  up,  and  rapidly  run  on  to  suppuration 
and  disorganization  of  the  joint.  The  peculiar  absorptive  power 
of  the  synovial  membrane,  moreover,  favours  the  entrance  of  the 
chemical  products  of  decomposition  into  the  system,  and  conse- 
quently enhances  the  risk  of  Septic  poisoning,  to  which,  or  to 
such  infective  processes  as  septicsemia  or  pysemia,  the  patient 
may  succumb.  Further,  should  he  survive  these  earlier  dangers 
of  blood-poisoning,  he  is  still  liable  to  fall  a  victim  to  hectic,  or 
to  exhaustion  or  lardaceous  disease  consequent  upon  the  pro- 
longed drain  on  the  system  attending  the  suppuration  in  the 
synovial  membrane,  the  articular  ends  of  the  bones,  and  the  sur- 
rounding soft  parts. 

Medium-sized  wounds  are  the  most  dangerous,  as  such  cannot 
always  be  rendered  aseptic  nor  drainage  be  effectually  secured. 
Punctured  wounds,  when  made  with  a  clean  instrament  and  in  an 
oblique  direction,  may  heal  under  appropriate  treatment  with- 
out any  inflammatory  or  other  trouble.  Should  septic,  or  infec- 
tive poisons,  however,  gain  admission  at  the  time  of  puncture,  or 
subsequently  through  neglect  of  the  wound,  or  should  the  joint 
not  be  kept  properly  at  rest,  a  punctured  wound  may  be  followed 
by  the  most  intense  inflammation  of  the  synovial  membrane,  and' 
total  disorganization  of  the  joint,  with  its  attendant  dangers  of 
blood-poisoning.  Extensive  and  lacerated  wounds  of  joints, 
when  not  sufficiently  severe  to  call  for  amputation  or  excision,  axe 
not  necessarily  a  source  of  extreme  anxiety,  as  they  usually  per- 
mit of  effectual  cleansing  and  drainage,  and  under  the  use  of  an- 
tiseptics may  heal  up  by  granulations  without  giving  rise  to  any 
serious  constitutional  disturbance.     In  such  cases,  however,  bony 


CONGENITAL   DISLOCATIONS.  1 93 

ankylosis  will  generally  ensue,  though  in  some  instances  the  car- 
tilages may  escape  destruction,  and  a  fairly  movable  and  useful 
joint  may  be  obtained. 

S(^ns. — When  the  joint  is  laid  freely  open  the  nature  of  the  in- 
jury is  obvious,  and  any  displacement  or  splintering  of  the  bones 
can  be  seen  or  ascertained  by  the  examination  with  the  finger. 
When  the  wound  is  of  a  punctured  character  and  the  incision  in 
the  skin  is  some  distance  from  the  joint,  the  signs  are  not  always 
so  apparent.  In  such  cases  an  account  of  the  depth  to  which  the 
instrument  penetrated,  and  the  direction  in  which  it  appeared  to 
run,  will  help  us  to  determine  whether  the  synovial  membrane 
has  been  entered.  The  escape  of  a  glairy  fluid  like  white  of  egg 
— the  synovial  secretion — will  make  the  diagnosis  certain.  If  in 
doubt,  the  case  should  be  treated  as  if  the  joint  had  been  opened, 
but  on  no  account  should  the  wound  be  probed  for  the  purpose 
of  setthng  the  point.  Should  inflammation  ensue,  the  signs  will 
be  the  same  as  those  of  acute  arthritis  (see  Diseases  of  Joints). 

The  treatment  will  depend  on  the  size  and  character  of  the 
wound,  the  joint  affected,  the  nature  of  the  complications,  and 
the  age  and  constitution  of  the  patient.  The  chief  indications 
are  to  prevent  inflammation  and  its  attendant  consequences,  or  if 
the  injury  is  of  a  very  severe  character,  to  endeavor  to  save  the 
patient's  life  by  the  sacrifice  of  his  limb.  Thus,  if  the  wound  is 
small  and  uncompUcated,  an  attempt  should  be  made  to  convert 
it  into  a  subcutaneous  wound  by  sealing  it  with  iodoformized  col- 
lodion, or  better  by  placing  over  it  an  antiseptic  dressing,  after 
having  first  thoroughly  cleansed  the  skin  and  rendered  it  aseptic. 
One  or  more  silver  or  chromicized  gut  sutures  may  first  be  inserted 
if  the  wound  is  tou  large  to  be  closed  in  this  way.  The  hmb  should 
be  then  placed  on  a  splint  at  perfect  rest,  and  cold  applied  by 
means  of  an  ice-bag  or  by  Leiter's  tubes.  Should  inflammation 
follow,  half  a  dozen  leeches  should  be  placed  over  the  joint,  and 
warm  applications  be  substituted  for  the  cold  ;  whilst  should  the 
local  and  constitutional  disturbance  increase  and  the  joint  become 
distended,  aspiration  should  be  practiced  to  reheve  tension,  opium 
given  to  soothe  the  pain,  and  the  treatment  persevered  in.  If, 
however, ///J  is  withdrawn  by  the  aspirator,  the  joint  should  be 
laid  freely  open,  drained,  dressed  antiseptically,  and  placed  in 
the  position  in  which,  should  ankylosis  ensue,  it  will  subsequently 
be  of  most  use.  If,  notwithstanding  free  incisions,  the  suppura- 
tion goes  on,  continuous  irrigation  with  some  weak  antiseptic  fluid 
may  be  tried,  or  the  whole  limb  kept  continuously  in  a  hot  bath, 
the  patient,  if  necessary,  as  in  the  case  of  the  knee,  being  himself 
immersed.  Should  signs  of  saprsemia  or  exhaustion  from  hectic 
set  in,  amputation  must  be  performed. 

9 


194  INJURIES   OF   SPECIAL   TISSUES. 

Larger  wounds  of  joints,  especially  when  lacerated,  should  be 
thoroughly  cleansed  with  antiseptic  lotions,  well  drained,  and 
dressed  antiseptically.  A  counter-opening  at  a  dependent'  spot 
may  in  some  cases  be  advantageously  made,  as  for  instance  in  the 
popliteal  space  in  wounds  of  the  knee,  and  a  tube  passed  through 
the  joint.  Where  there  is  extensive  laceration  of  the  soft  parts, 
much  comminution  of  the  bones,  or  other  complications  of  such  a 
nature  as  to  render  it  doubtful  whether  a  useful  limb  can  be  ob- 
tained, the  question  of  amputation  or  excision  must  be  raised.  In 
deciding  on  the  propriety  of  an  operation,  the  surgeon  will  be  in- 
fluenced by  the  situation  of  the  joint,  and  the  probable  power  of 
the  patient,  either  on  account  of  his  age  or  the  general  state  of 
his  constitution,  to  stand  the  acute  inflammation  and  prolonged 
suppuration  which  must  almost  necessarily  ensue  if  the  limb  is  not 
removed.  Briefly  it  may  be  said,  that  an  injury  in  which  the 
elbow  might  be  treated  in  the  ordinary  way  or  by  excision  of  the 
joint,  would  in  the  knee  probably  call  for  amputation  ;  that  a 
wound  in  the  wrist  is  generally  more  serious  than  one  of  the  ankle  ; 
and  that  the  sacrifice  of  the  limb  is  required  for  a  much  less  severe 
wound  of  the  knee  than  the  ankle. 

INJURIES    OF    MUSCLES   AND    TENDONS. 

Contusions  of  muscles  are  very  common  as  the  result  of  falls, 
blows,  kicks,  or  other  violence.  They  may  vary  from  a  slight 
bruising  with  or  without  tearing  of  the  muscle-fibres  and  blood- 
extravasation  to  complete  pulping  of  the  muscles.  Signs. — In  the 
slighter  cases  there  is  dull  aching  pain  increased  on  movement, 
ill-defined  and  deep  seated  swelling,  and  later,  ecchymosis  as  the 
blood  makes  .its  way  to  the  surface.  Some  stiffness  or  loss  of  power 
from  partial  atrophy  frequently  follows,  and  occasionally  inflam- 
mation and  abscess.  Severe  cases  are  frequently  associated  with 
other  injuries  of  the  part,  as  fracture  of  a  bone,  laceration  of  a 
large  blood-vessel,  etc.  The //r(2/W(?/?/consists  in  keeping  the  part 
at  rest  with  the  muscle  as  much  as  possible  relaxed,  and  in  pre- 
venting inflammation  by  cold,  lead  and  opium  lotions  and  the  like. 
Shampooing,  massage,  and  galvanism  may  subsequently  be  neces- 
sary to  restore  any  loss  of  power  that  may  ensue. 

Wounds  of  xMUScles  may  be  incised,  lacerated,  jjunctured,  or 
contused.  When  the  wound  is  made  transversely,  the  divided 
ends,  which  gape  widely,  must  be  approximated  by  placing  the 
limb  in  such  a  position  as  will' relax  the  muscle,  and  then  united 
by  aseptic  sutures.  When  the  wound  is  deep  or  parallel  to  the 
fibres,  a  drainage  tube  may  be  inserted  to  prevent  the  retention  of 
the  discharge  by  the  bulging  of  the  muscle.  Union  takes  place 
by  fibrous  tissue. 


DISLOCATION    OF   TENDON.  I95 

Rupture  of  muscle  may  occur  from  a  sudden  and  violent 
spasmodic  action,  or  during  vomiting,  tetanus,  or  delirium.  As 
examples  may  be  mentioned  rupture  of  the  sterno-mastoid  of  the 
child  in  a  difficult  labor,  the  rectus  abdominis  in  parturition,  the 
biceps  in  raising  weights,  the  supinator  longus  and  gastrocnemius 
in  lawn-tennis,  the  quadriceps  extensor  at  foot-ball,  and  the  adduc- 
tors of  the  thigh  in  riding.  A  sensation  of  tearing  is  often  felt 
at  the  moment  of  rupture,  followed  by  pain,  and,  if  the  rupture  is 
complete,  by  loss  of  function.  The  rupture  is  indicated  by  a  gap, 
above  and  below  which  is  felt  a  swelling  formed  by  the  ends  of 
the  retracted  muscle ;  or  blood  is  extravasated  betv/een  the  rup- 
tured ends,  occasioning  a  hsematoma.  Rupture  of  the  sterno- 
mastoid  in  infancy  is  said  to  be  followed  by  contraction  of  the 
muscle  and  consequent  wry-neck.  The  treatment  consists  in  ap- 
proximating the  divided  ends  as  much  as  possible  by  position  and 
by  suitable  bandages  and  splints,  and  in  applying  ice  and  evapo- 
rating lotions  to  control  the  blood  extravasation,  and  to  prevent 
inflammation.  If  a  blood-tumor  forms  it  should  not  be  opened, 
unless  suppuration  occurs. 

'Wounds  of  tendons  may  be  divided  into  the  subcutaneous 
and  the  open.  The  former  are  discussed  under  Tenotomy.  When 
a  tendon  is  divided  in  an  open  wound,  its  cut  ends  should  be 
approximated  by  placing  the  parts  on  a  splint  in  such  a  position 
that  the  muscle  is  as  much  as  possible  relaxed,  and  the  divided 
ends  then  united  by  aseptic  sutures.  In  long-standing  cases  an 
attempt  may  also  be  made  to  unite  the  cut  tendon  if  the  patient's 
general  state  of  health  is  favorable,  and  there  is  no  evidence  of 
extensive  destruction  of  the  tendon  or  of  its  adhesion  to  the 
neighboring  structures.  When  the  ends  of  the  divided  tendon 
are  found  to  have  retracted  and  to  be  so  far  apart  that  they  can- 
not be  made  to  meet,  one  end  may  be  split  longitudinally,  but 
not  quite  to  the  divided  end,  turned  down  and  united  to  the 
other  end  by  suture.  In  some  cases  where  the  divided  ends  will 
not  meet  they  may  be  united  by  a  leash  of  catgut.  In  other 
cases,  as  in  the  tendons  of  the  fingers,  the  distal  end  may  be 
united  laterally  to  a  neighboring  tendon. 

Dislocation  of  a  tendon  from  its  sheath  or  groove  without 
fracture  or  other  injury  occasionally  occurs  from  a  sudden  twist 
or  strain.  It  is  indicated  by  pain  and  partial  or  complete  loss  of 
function  of  the  affected  muscle,  swelhng  and  ecchymosis  ;  whilst 
on  examination,  the  displaced  tendon  may  sometimes  be  felt  in 
its  abnormal  situation.  The  injury  is  most  common  about  the 
ankle,  and  in  the  fore-arm,  back  and  neck.  The  treatment  con- 
sists in  replacing  the  tendon  by  manipulation,  breaking  down  any 
adhesions  that  may  have  formed,  and  retaining  it  in  place  (which 


196  INJURIES   OF   SPECIAL  TISSUES. 

is  often  difficult)  bv  a  suitably-applied  pad  and  bandage,  or  in 
the  case  of  the  ankle  or  wrist  by  a  plaster-of-Paris  bandage,  and 
subsequently  by  a  leather  support. 

Rupture  of  a  tendon  may  occur  as  the  result  of  external 
violence  or  during  some  sudden  and  involuntary  muscular  action, 
and  is  very  common  in  the  plantaris  and  tendo  Achillis,  and 
somewhat  less  so  in  the  biceps  (see  Injuries  of  the  Upper  and 
Lower  Extremity).  The  tendon,  except  when  the  ends  become 
widely  separated,  as  generally  happens  in  the  case  of  rupture  of 
the  long  tendon  of  the  biceps,  usually  unites  readily  on  the  ends 
being  approximated  and  kept  at  rest  in  that  position. 

Evulsion  or  tearing  out  of  a  tendon  with  part  of  its  muscle 
occasionally  occurs  as  the  result  of  catching  the  finger  or  thumb 
in  a  machine,  on  a  hook,  etc.  Part  or  the  whole  of  a  digit  is 
usually  torn  off,  bringing  away  with  it  the  fiexor  tendon,  this  being 
more  firmly  attached  to  the  bone  than  the  extensor.  In  conse- 
quence of  the  tendon-sheath  being  thus  left  open,  suppuration  is 
liable  to  extend  up  it  into  the  forearm.  Free  drainage  of  the 
wound  and  antiseptic  dressings  are  then  imperative. 

INJURIES    of    arteries. 

Contusion  or  bruising  of  an  artery  without  laceration  or  other 
injury  of  its  coats  is  of  occasional  occurrence,  and  is  said  to  be 
followed  by  contraction  and  permanent  diminution  in  the  size  of 
the  vessel,  and  even  by  gangrene  of  the  limb.  Little  that  is  defi- 
nite, however,  is  known  of  this  injury. 

Rupture  or  subcutaneous  laceration  of  an  artery  may  occur 
as  the  result  of  any  severe  violence,  but  is  perhaps  most  often  due 
to  the  passage  of  a  wheel  over  a  limb,  incautious  attempts  to  re- 
duce an  old  dislocation  of  the  shoulder,  and  excessive  violence  in 
breaking  down  adhesions  in  stiff  joints. 

1.  The  rupture  may  be  partial,  i.  e.,  the  internal  and  middle 
coats  only  may  be  torn.  In  such  a  case  the  external  coat  may 
subsequently  yield  to  the  pressure  of  the  blood,  thus  laying  the 
foundation  of  an  aneurysm  ;  or  the  internal  and  middle  coats 
may  be  folded  inwards  into  the  interior  of  the  vessel,  obliterating 
its  calibre,  and  in  this  way  may  cause,  esiDecially  if  the  vein  is 
also  injured,  gangrene  of  the  limb  (Fig.  56). 

2.  i'he  rupture  /nay  be  complete,  i.  e.,  all  the  coats  may  be  torn 
across.  Here  in  a  similar  manner  the  artery  may  become  oc- 
cluded without  any  haemorrhage  ;  or  blood,  often  in  enormous 
quantities,  may  be  poured  out  into  the  tissues  of  the  limb.  In 
either  case  gangrene  may  ensue,  especially  if  the  vein  is  also 
ruptured,  and  the  injury  occurs  in  the  lower  extremity.     Some- 


RUPTURE  OF  SUBCUTANEOUS  LACERATION. 


197 


Fig.  56. 


times  the  extravasated  blood,  particularly  in  the  upper  extremity, 
may  become  encysted,  a  sac  being  formed  for  it  by  the  inflamma- 
tion and  condensation  of  the  surrounding  tissues.  This  condition 
IS  called  a  circumscribed  traumatic  aneurysm  in  contradistinction 
to  diffused  traumatic  aneurysm,  the  term  sometimes  applied  to 
the  injury  when  the  blood  is  simply  extravasated  into  the  tissues, 
though  in  this  latter  case  the  name  ruptured  artery  is  more 
appropriatte. 

The  symptoms  vary  according  to  the  nature  of  the  injury. 
When  the  main  artery  becomes  occluded  there  will  be  pain  at 
the  seat  of  rupture  and  cessation  of  the  pulse 
below,  while  later  gangrene  will  probably, 
though  not  invariably,  ensue.  Should  the 
artery  not  be  occluded,  blood  in  large  quan- 
tities will  escape  into  the  tissues,  giving  rise 
to  a  rapidly-increasing  swelling,  in  which  on 
pulsation  can  be  detected,  although  a  bruit 
may  sometimes  be  heard  ;  the  limb  becomes 
cold,  livid,  and  swollen,  and  the  pulse,  as  a 
rule,  can  no  longer  be  felt  in  the  arteries 
below.  When  the  extravasation  is  very  large, 
constitutional  symptoms  of  haemorrhage  will 
also  be  present,  and  signs  of  gangrene,  if  the 
ruptured  artery  is  in  the  lower  limb,  will 
probably  soon  supervene,  since  not  only  is 
the  main  arterial  supply  cut  off,  but  the  col- 
lateral flow  and  venous  return  are  also  im- 
peded by  the  pressure  of  the  extravasated 
blood  on  the  collateral  arteries  and  veins. 
On  the  other  hand,  should  the  blood,  as  oc- 
casionally happens  in  the  upper  limb,  become  encysted,  the 
swelhng  will  slowly  assume  the  characters  of  an  ordinary 
aneurysm. 

Treatment. —  (a)  When  the  artery  is  occluded  all  that  can  be 
done  is  to  endeavor  to  prevent  gangrene  occurring  by  maintaining 
the  warmth  of  the  limb  till  the  collateral  circulation  has  had  time 
to  become  established.  Should  gangrene  occur,  amputation  must 
be  performed  as  soon  as  a  line  of  demarcation  has  formed,  (b) 
When  blood  in  large  quantities  is  extravasated  into  the  tissues  the 
treatment  will  depend  on  the  situation  of  the  ruptured  artery. 
Thus,  in  the  case  of  the  popliteal,  amputation  is  usually  called  for, 
especially  if  the  vein  is  also  ruptured,  as  gangrene,  for  the  reasons 
stated  above,  will  almost  invariably  ensue  if  the  main  artery  is 
tied  either  above  or  at  the  seat  of  rupture.  In  the  case  of  the 
axillary,  however,  where  the  collateral  circulation  is   much  more 


Obliteration  of  the  sub- 
clavian artery  by  the 
infolding  of  the  internal 
and  middle  coats  with- 
out injury  of  the  ex- 
ternal coat. 


198  IN7URIES   OF   SPECIAL   TISSUES. 

free,  the  ruptured  artery  may  be  cut  down  upon  and  secured  above 
and  below  the  bleeding  spot. 

Wounds  of  arteries  may  be  divided  into  the  penetrating  and 
the  non-penetrating. 

T.  The  non  penetratiiiiy^  are  those  in  which  either  the  outer  only, 
or  the  outer  and  middle  coats,  are  notched  or  torn.  Here  the  wound 
may  heal,  or  the  uninjured  coat  or  coats  may  ulcerate,  give  way^ 
and  haemorrhage  ensue,  or  may  gradually  yield,  as  may  also  the 
cicatrice  left  on  the  healing  of  the  wound,  to  the  pressure  of  the 
blood,  and  lead  to  the  formation  of  an  aneurysm. 

2.  The peneiraiiuo  are  those  in  which  the  interior  of  the  artery 
is  laid  open.  In  this  case  much  will  depend  upon  the  size  of  the 
artery,  and  whether  it  is  completely  or  only  partially  cut  across, 
and  upon  the  direction  and  size  of  the  wound. 

(a)  Wou7ids  of  large  arteries,  as  the  aorta  or  puhnonary  artery, 
whatever  their  nature,  are  usually  immediately  fatal. 

(b)  Wounds  of  arteries  of  the  second  and  thij-d  degree,  as  the 
femoral  and  brachial.  If  the  artery  is  completely  divided,  and  the 
edges  of  the  wound  are  cleanly  cut,  repeated  haemorrhages  rapidly 
terminating  in  death  will  generally  ensue  ;  but  if  the  edges  are 
uneven  and  ragged,  as  in  the  avulsion  of  a  limb  by  machinery  or 
by  a  cannon-ball,  the  external  coat  becomes  twisted  up,  and  the 
middle  and  internal  coats  retract  and  contract,  a  clot  forms  within 
the  vessel,  and  no  haemorrhage  occurs.  If  the  artery  \%  partially 
divided  and  the  wound  is  made  transversely  to  the  long  axis  of  the 
vessel,  the  longitudinal  tension  of  the  elastic  coat  causes  the  wound 
to  assume  a  diamond  shape,  and  severe  haemorrhage  will  ensue  ; 
but  if  the  wound  is  made  parallel  to  the  long  axis  of  the  vessel, 
and  is  small  (a  mere  puncture)  it  may  heal  by  adhesive  inflam- 
mation. In  the  latter  instance  the  cicatrix  may  remain  per- 
manent, or  it  may  subsequently  yield,  iiroducing  a  traumatic 
aneurysm. 

(c)  Wounds  of  medium-sized  arteries,  as  the  radial  and  tibials, 
are  attended  when  the  vessel  is  completely  and  evenly  divided  by 
sharp  haemorrhage,  followed  by  syncope,  and  temporary  arrest 
from  the  formation  of  a  clot.  The  artery  may  then  become  per- 
manently occluded ;  usually,  however,  as  the  heart's  power  is 
restored  the  clot  is  washed  away  and  haemorrhage  recurs.  In  this 
way  haemorrhages,  alternating  with  temporary  arrests,  continue 
until  death  ensues  from  exhaustion.  When  the  edges  of  the 
wound  are  uneven,  or  the  artery  is  only  partially  divided,  the 
effects  are  similar  in  each  case  to  those  described  above  in  arte- 
ries of  larger  size. 

(d)  Wounds  of  small  arteries. —  If  the  artery  is  completely 
divided  it  will    usually  become  occluded    in    the  way  described 


TREATMENT    OF    WOUNDED   ARTERIES.  1 99 

under  nature's  method  of  arresting  haemorrhage  (p.  126)  ;  but  if 
only  partially  divided  such  occlusion  does  not  as  a  rule  take  place, 
and  repeated  heemorrhages  follow.  Complete  division  will  then 
often  suffice  to  cause  its  occlusion,  a  plan  which  was  frequently 
resorted  to  when  bleeding  from  the  temporal  was  practised. 

When  the  wound  through  the  soft  tissues  leading  to  a  wounded 
artery  is  small  or  of  a  punctured  character,  the  superficial  part  of 
the  wound  may  close,  whilst  the  blood  continues  to  be  extrava- 
sated  from  the  wounded  vessel  into  the  deeper  part,  where  it  may 
become  encysted  from  the  condensation  of  the  soft  tissues  around 
{^circumscribed  traumatic  aneurysm). 

Treatment  OF  wounded  arteries. — i.  When  an  artery  is  seen 
spouting  in  an  open  wound,  a  ligature  should  at  once  be  applied 
to  the  bleeding  end.  Other  methods  of  securing  the  vessel,  as 
torsion  or  acupressure,  may  of  course  be  used  if  preferred ;  but 
as  the  ligature  is  almost  invariably  used  at  my  own  school,  I  shall, 
to  prevent  repetition  of  what  has  been  already  said  under  arrest 
of  haemorrhage  (p.  126),  speak  of  ligature  only  in  the  context. 

2.  When  the  end  of  a  large  artery  is  seen  pulsating,  but  not 
bleeding  in  consequence  of  it  having  been  torn  across,  I  should, 
myself,  apply  a  ligature  to  it  as  a  precaution,  though  by  some  this 
would  not  be  considered  necessary. 

3.  When  an  artery  is  exposed  for  some  distance  in  its  continuity, 
two  ligatures  had  better  as  a  rule  be  applied  and  the  artery 
divided  between  them,  especially  if  it  be  notched  or  bruised. 

4.  When  an  artery  has  ceased  to  bleed,  even  though  the  haem- 
orrhage may  have  been  sharp,  the  wound  should  on  no  account 
be  enlarged  for  the  purpose  of  tying  the  bleeding  vessel,  unless  it 
can  be  seen  or  felt ;  since  not  only  may  it  not  bleed  again,  but  as 
the  bleeding  has  ceased  it  may  also  be  difficult  or  impossible  to 
find  it.  In  such  a  case,  however,  especially  if  the  patient  is  much 
collapsed,  he  should  be  watched  for  the  first  sign  of  any  return  of 
the  haemorrhage,  firm  pressure  in  the  meantime  being  applied 
over  the  wound,  and  where  practicable  over  the  course  of  the 
main  artery  above  and  below.  The  whole  limb,  moreover,  should 
be  carefully  bandaged  from  below  upwards. 

5.  When  the  hjemorrhage  is  moderate  and  clearly  arterial,  the 
external  wound  small,  and  the  artery  not  seen,  pressure  should  be 
applied  in  the  way  mentioned  above,  and  will  probably  suffice. 

6.  When  the  bleeding  is  severe  and  evidently  arterial,  and  the 
external  wound  is  still  open,  whether  the  wound  be  deep,  recent, 
inflamed,  or  sloughing,  the  well-established  rule,  to  which,  how- 
ever, there  are  of  course  exceptions,  is  to  cut  dotcn  upon  the  bleed- 
ing point  and  apply  a  ligature  to  each  end  of  the  artery  if  divided, 
or  above  and  below  the  wound  if  the  artery  is  punctured  or  only 


200 


INJURIES   OF    SPECIAL   TISSUES. 


Fig.   57. 


partially  cut  across.  To  do  this  it  is  generally  sufficient  to  en- 
large the  wound  in  the  soft  tissues  ;  but  where  the  wound  is  on 
one  side  of  the  limb  and  the  bleeding  apparently  comes  from  an 
artery  on  the  other,  a  probe  should  be  passed  through  the  wound, 
its  projecting  point  cut  down  upon,  and  the 
bleeding  artery  sought  through  this  incision  and 
tied  as  above.  The  object  of  this  procedure  is 
to  prevent  the  necessity  of  making  a  very  large 
wound. 

The  reasons  for  t\iiig  an  artery  at  the  place 
where  it  is  wounded  are  : — i.  It  is  often  impos- 
sible to  determine,  without  cutting  down  upon 
it,  what  artery  is  bleeding,  and  should  the  al- 
ternative plan  of  securing  the  main  artery  higher 
up  be  adopted,  the  wrong  artery  after  all  may 
be  tied  and  the  bleeding  continue.  Thus,  for 
example,  in  a  supposed  wound  of  the  femoral 
VA  11         it  might  be  the  profunda,  or  even  a  small  mus- 

^'\        ^V/  cular  branch  that  was  bleeding.     2.  Even  sup- 

posing the  main  trunk  were  the  one  wounded, 
the  blood  might  still  be  carried  by  the  collateral 
vessels  into  the  artery  beyond  the  ligature, 
either  above  or  below  the  wound  in  the  vessel, 
and  bleeding  recur  from  either  the  proximal  or 
distal  end  (Fig.  57).  3.  Should,  moreover, 
ligature  of  the  main  artery  higher  up  thus  fail  to 
arrest  the  haemorrhage,  not  only  will  the  patient 
be  further  reduced  by  loss  of  blood,  but  the 
subsequent  ligature,  which  will  then  probably  in 
the  end  have  to  be  applied  to  the  bleeding 
artery  in  the  wound,  may  through  the  extra 
interference  with  the  collateral  vessels  induce 
gangrene  of  the  limb.  4.  Tying  the  main  artery 
above  is  in  itself  in  some  cases  a  more  dangerous  and  difficult 
procedure  than  enlarging  the  wound. 

The  reason  for  applyini^  a  ligature  to  both  ends  of  the  vessel  if  it 
is  divided,  or  above  and  beloiv  the  wound  if  it  is  7nerely  punctured 
or  only  partially  cut  across,  \^  that  ligature  of  the  proximal  end 
only  may  be  insufficient  to  arrest  the  h?emorrhnge,  since_  the 
blood,  as  seen  in  Fig.  57,  may  be  carried  round  by  the  collateral 
channels  into  the  artery  below  the  wound,  and  may  thence  escape 
by  the  open  distal  end. 

In  some  instances  the  above  rule  of  cutting  down  upon  and 
tying  the  artery  at  the  wounded  spot  cannot  be  carried  out. 
Thus,  where  the  artery  is  inaccessible,  as  in  punctured  wounds  of 


Diagram  to  illustrate 
the  manner  in 
which,  after  a  lig- 
ature has  been  ap- 
plied at  a  distance 
from  a  wound  in  an 
arlerv,  the  blood 
may  te  carried  back 
again  into  the  artery 
above  and  below  the 
wounded  spot  by 
collateral  vessels. 
The  arrows  indicate 
the  direction  of  the 
blood  current.   " 


TRAUMATIC  ANEURYSM.  20r 

the  tonsil,  or  about  the  angle  of  the  jaw  ,•*  or  where  important 
structures  would  be  damaged  by  enlarging  the  wound,  as  the 
tendons  in  the  palm  of  the  hand  in  wounds  of  the  palmar  arch,  it 
may  be  necessary  to  tie  in  the  former  case  one  of  the  carotids,  in 
the  latter  the  brachial.  Moreover,  it  may  at  times  be  safer  to  re- 
move a  limb  than  to  search  for  the  bleeding  vessel,  as  for  instance 
in  wounds  of  the  posterior  tibial  artery  in  the  upper  third  of  the 
leg,  especially  if  the  injury  is  complicated  by  fracture.  Again,  it 
may  not  only  be  found  impracticable  to  ligature  the  artery  at  the 
wounded  spot,  but  also  impossible  to  tie  or  even  compress  the 
main  vessel  nearer  the  heart,  as  for  instance  in  wounds  of  the  sub- 
clavian above  the  clavicle.  Here  all  that  can  probably  be  done 
is  to  trust  to  pressure  firmly  appHed  to  the  wound. 

Whilst  cutting  down  upon  a  bleeding  artery  hgemorrhage  should 
be  restrained  by  the  use  of  an  Esmarch's  bandage,  or  by  the 
tourniquet  or  the  fingers  applied  to  the  main  artery  above  the 
wound  ;  and  in  the  case  of  a  wound  of  the  external  iliac  or 
gluteal,  by  Davy's  lever  passed  up  the  rectum  and  made  to  com- 
press the  common  iliac.  Where  it  is  impracticable  to  control 
the  bleeding  in  any  of  these  ways,  the  wound,  if  necessary,  should 
be  sufficiently  enlarged  to  admit  one  or  two  fingers,  and  the 
bleeding  vessel  having  been  recognized  by  the  escape  of  warm 
blood,  should  then  be  compressed  by  the  finger,  the  wound  farther 
enlarged,  and  the  artery  secured  with  the  aid  of  an  assistant  be- 
fore the  finger  is  removed  from  the  bleeding  spot. 

Should  gangrene  ensue  after  ligature,  and  spread  rapidly,  ampu- 
tation must  be  performed  at  the  seat  of  ligature  ;  but  if  it  involves 
only  one  or  two  fingers  or  toes,  or  spreads  slowly,  a  line  of  de- 
marcation should  be  waited  for  before  amputating. 

Traumatic  aneurysm. — Two  forms  are  described,  the  diffuse 
and  the  circumscribed. 

The  diffuse  is  practically  a  ruptured  or  wounded  artery  with 
extravasation  of  blood  into  the  tissues.  There  is  no  attempt  at 
the  formation  of  a  sac,  and  the  term  aneurysm  applied  to  it  is 
misleading.     (See  Ruptured  Artery,  p.  196.) 

The  circumscribed  may  be  formed  in  several  ways,  as  already 
stated  under  Rupture  and  Wounds  of  Arteries.  Thus,  i.  An  ar- 
tery may  be  wounded,  pressure  be  applied,  the  external  wound 
heal,  and  blood  slowly  escape  into  the  tissues.  2.  An  artery  may 
be  wounded,  heal,  and  the  cicatrix  subsequently  yield.  3.  An 
artery  may  without  external  wound  be  punctured  by  a  fragment 
of  fractured  bone,  or  torn  in  reducing  a  dislocation,  and  blood  in 
either  case  be  extravasated  into  the  tissues.  4.  An  artery  may 
be  wounded  but  not  penetrated,  and  the  uninjured  coat  or  coats 
may  yield  to  the  pressure  of  the  blood.     In  all  of  these  cases  the 


202  INJURIES    OF    SPECIAL   TISSUES. 

soft  tissues  around  become  condensed  and  form  the  sac  of  the 
aneutysm.  Where  the  aneurysm  is  produced  by  the  yielding  of 
any  portion  of  the  arterial  coat,  this  at  first  will  form  the  sac,  but 
sooner  or  later  it  will  give  way,  and  the  sac  will  then  be  formed 
by  the  condensation  of  the  soft  tissues  around,  as  when  the  blood 
escapes  directly  into  the  tissues.  The  course,  termination,  and 
signs  of  a  circumscribed  traumatic  aneurysm  are  similar  to  those 
of  a  spontaneous  aneurysm.  The  treatment,  however,  inasmuch 
as  the  artery  in  the  neighborhood  of  the  sac  will  probably  be 
healthy,  differs  from  the  treatment  of  a  spontaneous  aneurysm,  in 
that  the  artery  may  be  tied  immediately  above  the  sac,  or  the 
sac  may  be  laid  open  and  the  vessel  tied  above  and  below.  Thus, 
if  the  injured  artery  is  small,  it  may  be  tied  above  and  below ;  if 

large,  immediately  above,  un- 
FiG.  s8.  less  the  aneurysm  threatens  to 

—^  i«s^      ii?*^  ^^  burst,    under    which     circum- 

5^   ^  gf  -^  Stances   the    aneurysm    should 


be  laid  open  and  the  artery 
tied  where  it  enters  and  leaves 
the  sac. 

A RTERIO  VENOUS  ANEURYSM  is 

a   pulsating   tumor  depending 
f         upon  an  abnormal  communica- 
tion of  an  artery  with  a  vein. 
There  are  two  kinds :  in  one 
*^-2  A  \j^  <ii»jj  V3ii  the     communication     between 

"  the  artery  and   vein   is  direct 

Diagram  of   arterio-venous   aneurysm,      a.         , -n.-  o    \  j      ^j         ort-prinl 

Aneurysmal  varix.    n.  Varicose  aneurysm.         \ -••  '&•     j"^/>     "i'>-i      f*^     tii  tci  lai 

blood  is  forced  into  the  vein  at 
each  beat  of  the  heart,  causing  its  walls  to  be  dilated  into  a  fusi- 
form or  sac-like  swelling  {aneurysmal x^arix)  ;  in  the  other  (Fig. 
5815),  the  blood  first  passes  into  a  small  aneurysm  formed  by  con- 
densation of  the  tissues  between  the  artery  and  vein  and  thence 
into  the  vein,  the  dilatation  of  the  vein  being  consequently  less 
than  in  the  preceding  variety  {luiricosc  aneurysm) .  Both  forms 
may  occur  spontaneously,  but  are  usually  the  result  of  some  in- 
jury, as  a  stab,  wounding  the  walls  of  both  vessels.  The  lesion 
was  of  common  occurrence  at  the  bend  of  the  elbow  when  vene- 
section was  in  vogue,  the  lancet  passing  through  the  median 
basilic  vein  and  bicipital  fascia  into  the  subjacent  brachial  artery. 
Si\^ns. — An  aneurysmal  varix  gives  rise  to  a  pulsating  tumor  in 
which  a  peculiar  bru't,  compared  to  the  buzzing  of  a  fly  in  a 
l)Tper  box,  is  heard.  The  artery  is  dilated  and  thinned  above 
owing  to  the  impediment  to  the  circulation,  and  is  smaller  below  ; 
whilst   the   vein   is  dilated,   especially  above,  and   j^ulsates.     In 


WOUNDS.  203 

varicose  aneurysm,  in  addition  to  the  above  signs,  wliich  are  com- 
mon to  both  forms,  an  ordinary  aneurysmal  bruit  can  be  heard. 
Treatment. — In  aneurysmal  varix  some  form  of  elastic  support 
should  be  applied,  or  if  the  swelling  is  increasing,  the  artery  tied 
above  and  below  its  point  of  communication  with  the  vein.  In 
varicose  aneurysm  pressure  may  first  be  applied  to  the  artery 
above  the  sac,  combined  with  direct  pressure  on  the  sac.  If  this 
fails  the  artery  must  be  tied  above  and  below  the  sac,  since  if  left 
to  nature  there  is  grave  danger  of  rupture  and  haemorrhage. 
When  the  carotid  or  the  femoral  artery  and  the  adjoining  veins  are 
the  subject  of  the  lesion,  no  operative  treatment  as  a  rule  should 
be  undertaken  unless  the  lesion  is  recent,  and  the  blood  as  well  as 
passing  into  the  vein  is  being  likewise  extravasated  into  the 
tissues,  and  threatening  to  break  through  the  external  wound.  In 
such  a  case,  should  pressure  applied  to  the  main  artery  and  over 
the  site  of  the  wound  fail,  the  artery  must  be  cut  down  upon  and 
tied  above  and  below  the  wound.  Unless  pressure  controls  the 
hsemorrhage  from  the  vein,  a  lateral  ligature  must  be  placed  on 
the  wound  in  its  wall,  or  if  the  wound  is  too  large  to  admit  of  this 
being  done,  the  whole  vein  may  be  tied  above  and  below  the 
wound,  and  then  divided  between  the  ligatures. 


INJURIES    OF    VEINS. 

•  Rupture  or  subcutaneous  laceration  of  a  vein  occasionally  oc- 
curs from  causes  similar  to  those  producing  rupture  of  an  artery, 
an  accident  moreover  with  which  it  is  frequently  associated. 
When  the  vein  is  of  large  size,  much  blood  may  be  extravasated 
into  the  tissues  and  may  produce  gangrene  by  pressure  on  the 
vessels  carrying  on  the  collateral  circulation,  though  such  a  result 
is  much  less  common  than  after  rupture  of  an  artery.  The  blood, 
except  when  the  extravasation  is  large,  is  usually  absorbed,  but 
may  break  down  and  suppuration  ensue. 

Wounds. — Punctured  and  incised  wounds,  when  small  and 
parallel  to  the  long  axis  of  even  large  veins,  readily  heal  by  adhe- 
sive inflammation  without  obliteration  of  the  lumen  of  the  vessel. 
At  times,  however,  a  clot  may  form  in  the  wound,  and  successive 
layers  be  deposited  upon  it  until  ultimately  the  vein  is  occluded. 
When  a  vein  is  completely  cut  across,  as  in  amputation,  it  usually 
collapses  as  far  as  the  next  pair  of  valves,  a  clot  forms  as  high  as 
the  first  collateral  branch,  and  the  vein  becomes  permanently  oc- 
cluded in  a  way  similar  to  that  described  under  Healing  of 
Wounded  Arteries.  In  consequence,  however,  of  the  vein-wall 
containing  less  elastic  and  muscular  tissue  than  an  artery,  bleed- 
ing sometimes  continues  unless  stopped  artificially. 


204:  INJURIES   OF   SPECIAL  TISSUES. 

Treatment. — When  the  wound  is  a  mere  puncture  in  the  con- 
tinuity of  the  vein,  unless  it  is  found  that  pressure  will  control  the 
haemorrhage,  the  coats  should  be  nipped  up  by  forceps  and  a 
lateral  ligature  applied.  If  a  vein  continues  to  bleed  during  an 
amputation,  it  should  be  tied  like  an  artery.  A  large  wound,  or 
one  made  in  the  longitudinal  axis  of  a  large  vein,  necessitates 
ligature  of  the  vein  in  two  place,  and  the  division  of  the  vessel 
between  the  two  hgatures. 

T.\\t  dangers  of  wounds  of  veins  <vi^: — i.  Haemorrhage.  2.  In- 
flammation of  a  septic  character,  and  the  attendant  risks  of  blood- 
poisoning  from  the  detachment  of  the  infected  clots.  3.  Entrance 
of  air. 

Entrance  of  air  into  veins  is  fortunately  a  rare  accident.  It 
sometimes  happens  in  operations  about  the  root  of  the  neck, 
where  the  disposition  of  the  cervical  fascia  prevents  the  veins 
collapsing  and  thus  allows  air  to  be  sucked  in  during  inspiration. 
Air  is  known  to  have  entered  a  vein  by  the  hissing  sound  during 
inspiration,  the  escape  of  frothy  blood  from  the  vein  on  expira- 
tion, the  urgent  dyspnoea,  and  the  state  of  collapse  into  which  the 
patient  immediately  falls.  On  listening  over  the  heart  a  peculiar 
churning  sound  can  be  heard.  Death  in  fatal  cases  usually  occurs 
in  a  {t\\  minutes  and  is  due  to  the  admixture  of  blood  and  air 
preventing  the  circulation  through  the  capillaries  of  the  lungs  and 
so  causing  distension  and  paralysis  of  the  right  side  of  the  heart. 
Trentiuent. — The  finger  should  at  once  be  placed  over  the  hole  in 
the  vein  to  prevent  more  air  entering,  and  a  clamp  or  ligature 
applied  as  soon  as  practicable.  Pouring  water  into  the  wound 
has  been  suggested  both  as  a  means  of  preventing  the  further  en- 
trance of  air  during  inspiration,  and  of  allowing  that  which  is 
already  in  to  bubble  out  during  expiration.  The  patient  should 
be  placed  with  his  head  low  to  ensure  a  sufficient  supply  of  blood 
to  the  brain,  and  for  the  same  i)urpose  the  arteries  of  the  extrem- 
ities should  be  compressed,  whilst  injections  of  ether  or  brandy 
should  be  given  subcutaneously  to  stimulate  the  heart.  Aitificial 
respiration  should  not  be  performed  till  the  vein  is  secured,  lest 
more  air  be  sucked  in.  To  guard  against  the  accident  the  veins 
should  be  clamped  before  division,  and  in  removing  a  tumor 
traction  should  not  be  made  at  the  moment  the  vein  is  severed. 

INJURIKS   OF    NKRVF.S. 

Wounds  of  nkrvfs. — A  nerve  may  l)e  completely  or  partially 
divided,  and  the  wound  may  be  of  an  incised,  lacerated,  contused 
or  punctured  character. 

Pathology. — After  complete  division  of  a  nerve  the  divided  ends 


WOUNDS   OF   NERVES.  205 

slightly  retract,  and  should  union  not  be  effected,  either  naturally 
or  by  surgical  means,  the  portion  of  nerve  below  the  injury,  being 
cut  off  from  its  trophic  centre,  undergoes  atrophy  and  degenerates 
throughout  its  entire  length  {Wallerian  degeneration').  In  the 
meanwhile  the  portion  of  nerve  immediately  above  the  wound  is 
converted  into  a  bulbous  swelling  by  the  proliferation  of  the 
fibrous  tissue  of  the  sheath  and  its  prolongations  within  the  nerve. 
The  nerve-fibres  within  the  bulbous  end,  being  compressed  by 
the  newly-formed  tissue,  undergo  atrophy  and  degeneration,  but 
the  rest  of  the  nerve  above  the  injury  remains  unimpaired.  On 
microscopic  examination  of  the  bulbous  end,  numerous  young 
nerve-fibres  are  seen  in  the  fibrous  tissue  (Bowlby).  Should 
union  on  the  other  hand  occur,  the  process  by  which  it  is  effected 
is  briefly  as  follows  :  Inflammatory  material  is  thrown  out  between 
the  divided  ends,  and  forms  a  delicate  fibrous  network  bridging 
the  gap ;  into  this  the  axis-cylinders  of  the  upper  end  are  said  to 
grow  out  and  unite  with  the  degenerated  axis-cylinders  in  the 
lower  end,  which  then  becomes  gradually  restored  from  above 
downwards.  By  some  it  is  believed  that  new  axis-cyhnders  "  are 
developed  from  the  nuclei  of  the  sheath  of  Schwann  in  both  the 
proximal  and  peripheral  ends"  (Bowlby).  The  exact  manner, 
however,  in  which  the  union  and  regeneration  of  the  nerve  is 
brought  about  is  hardly  accurately  known.  When  a  nerve  is  only 
partially  cut  across,  the  divided  portions  may  unite  in  the  way 
above  described,  or  they  may  become  involved  in  the  scar  result- 
ing on  the  healing  of  the  soft  tissues,  and  then  prove  a  source  of 
much  irritation  to  the  seat  of  the  nerve. 

The  effects  of  wounds  of  nerves  in  addition  to  the  degeneration 
of  the  portion  below  the  wound  are  : — i.  Paralysis  of  motion  and 
sensation  of  the  parts  supplied  by  the  nerve.  2.  Subsequent 
wasting,  atrophy,  and  fatty  degeneration  of  the  paralyzed  muscles. 
3.  Certain  trophic  changes  in  the  tissues  whose  nutrition  is  pre- 
sided over  by  the  injured  nerve,  such  as  a  glazed,  smooth,  cold 
and  bluish-red  condition  of  the  skin,  falling  off  of  the  hair,  crack- 
ing and  deformity  of  the  nails,  local  ulcerations  and  gangrene  of 
the  fingers,  etc.  4.  A  marked  diminution  of  the  temperature  of 
the  part,  which  may  be  preceded  for  a  few  days  or  even  a  few 
weeks  by  a  slight  increase  of  two  or  three  degrees.  5.  Affections 
of  the  joints  resembling  rheumatism,  and  apt  to  terminate  in  more 
or  less  complete  ankylosis.  6.  Ascending  neuritis,  which  is  at- 
tended with  severe  pain  in  the  cicatrix,  pain  shooting  up  the 
nerve,  and  pain  in  the  area  of  its  distribution,  and  7.  Very  rarely, 
changes  in  the  nerve  centres  of  a  functional  or  of  an  organic 
nature. 

Signs. — The  immediate  symptoms  are  loss  of  function  in  the 


206  INJURIES   OF   SPECIAL   TISSUES, 

parts  supplied  by  the  nerve,  viz.,  muscular  paralysis,  local  anaes- 
thesia, or  loss  of  special  sense,  according  as  a  motor,  sensory,  or 
nerve  of  special  sense  is  injured.  In  the  case  of  a  mixed  nerve 
both  motion  and  sensation  will  be  lost ;  but  sensation  in  some  in- 
stances may  be  partially  restored  in  a  few  days  through  anasto- 
mosing branches  from  other  nerves.  The  remoter  symptoms  are 
wasting  of  the  muscles,  and  the  trophic  changes  of  the  skin,  nails, 
etc.,  already  alluded  to,  and  sometimes  pain  in  the  cicatrix,  and 
in  the  course  of  the  nerve  and  its  peripheral  distribution.  The 
muscles  exhibit  to  electrical  tests  the  reaction  of  degeneration, 
i.  €.,  they  do  not  respond  to  the  Faradic  current,  but  contract  on 
the  application  of  a  continuous  current  of  less  strength  than  that 
necessary  to  cause  the  contraction  of  normal  muscles ;  the  con- 
traction elicited,  moreover,  is  slow,  long,  and  tetanic ;  and  the 
sequence  of  polar  reaction  is  altered  (//COCCC  instead  of 
CCC.'>ACC.).  Their  response,  however,  to  the  continuous 
current  becomes  less  and  less  till  they  finally  cease  to  contract  at 
all.  As  a  consequence  of  the  degeneration  of  the  affected  mus- 
cles their  opponents  undergo  adaptive  shortening,  thus  producing 
various  deformities,  as  for  example  the  hammer  fingers  {main 
en  griffe)  seen  after  division  of  the  ulnar  nerve. 

The  treatment  varies  according  as  the  wound  of  the  nerve  is 
recent  or  of  long  standing.  In  the  former  case  the  nerve  should 
be  sought  in  the  wound,  the  divided  end  sutured,  the  limb  placed 
at  rest  on  a  splint  in  such  a  position  that  the  united  ends  are  not 
subjected  to  tension,  and  every  effort  subsequently  made  to  ob- 
tain healing  of  the  wound  of  the  soft  parts  by  the  first  intention. 
If  the  divided  ends  of  the  nerve  are  lacerated  or  contused,  the 
injured  portions  should  be  cleanly  cut  away  before  applying  the 
sutures.  If  the  nerve  is  only  partially  divided  the  divided  parts 
should  be  sutured.  The  sutures,  consisting  of  fine  China  twist, 
should  be  passed  v.'ith  a  small  curved  needle  through  the  sheath 
of  the  nerve  in  four  or  five  places.  At  St.  Bartholomew's  one  of 
the  sutures  is  generally  passed  completely  through  the  nerve,  a 
quarter  of  an  inch  from  the  divided  ends,  to  ensure  a  better 
hold.  In  every  recent  wound  it  should  be  as  much  a  matter  of 
routine  to  suture  large  nerves  if  divided,  as  to  tie  wounded  arter- 
ies. If  the  nerve  does  not  unite,  an  attempt  may  be  made  to 
procure  union  after  the  wound  is  healed,  as  may  also  be  done  in 
long-standing  cases  of  non-union,  though  many  months  or  even  a 
year  or  two  may  have  elapsed.  An  incision  over  the  ununited 
ends  should  be  made  parallel  to  the  nerve,  the  bulbous  upper 
end  of  which  can  generally  be  felt  through  the  soft  tissues.  The 
ends,  which  may  have  retracted  so  as  to  be  as  much  as  an  inch  or 
more  apart,  should  be  sought,  the  bulbous  ends  shaved  away  little 


COMPRESSION   OF   A   NERVE.  20'J  ■ 

by  little  with  a  sharp  scalpel  till  plenty  of  nerve-fibres  are  seen  on 
the  surface  of  the  section,  the  lower  end  also  refreshed  and  the 
two  united  in  the  manner  described  above.  Where  the  ends  are 
embedded  in  much  cicatricial  tissue  they  should  be  freed  by 
careful  dissection,  and  when  much  separated  stretched  so  as  to 
bring  them  into  apposition.  If  the  nerve  is  only  partially  di- 
vided, and  the  divided  portions  are  bound  down  by  cicatricial 
tissue,  the  injured  segment  of  nerve,  in  its  entire  thickness, 
should  be  cut  away  before  applying  the  sutures.  In  some  in- 
stances sensation  may  return  within  twenty-four  hours  of  suture ; 
but  it  may  be  more  than  a  year  in  long-standing  cases  before  the 
function  of  the  nerve  is  restored.  In  the  meanwhile  the  nutrition 
of  the  parts  supplied  by  it  should  be  promoted  by  warmth,  and 
the  muscles  prevented  as  much  as  possible  from  degenerating  by 
galvanism,  massage,  friction,  and  passive  movements. 

Transplantation  of  nerves  or  nerve-grafting. — since  the  publi- 
cation of  Mr.  Mayo  Robson's  successful  case  of  transplantation 
of  a  portion  of  the  posterior  tibial  nerve  taken  from  an  amputated 
limb  in  the  gap  left  in  the  median  nerve  on  the  removal  of  a 
tumor,  the  operation  of  nerve-grafting  has  become  a  recognized 
surgical  procedure.  In  some  cases,  also,  a  piece  of  nerve  has 
been  taken  from  an  animal  for  the  same  purpose.  An  attempt  to 
restore  the  function  of  the  nerve  in  this  way  may  be  made  where 
the  proximal  and  the"  distal  ends  of  a  divided  nerve  cannot  be 
brought  into  apposition,  as,  for  instance,  after  a  portion  of  nerve 
has  been  destroyed  in  a  compound  fracture,  or  after  a  portion  of 
nerve,  damaged  by  the  contraction  of  cicatricial  tissue,  by  the 
formation  of  callus  or  by  the  growth  of  a  tumor  in  its  substance, 
has  been  removed.  The  conditions  for  success  are  : — Great  care 
in  dissecting  out  and  handling  the  nerve,  its  immediate  transfer- 
ence, the  employment  of  a  single  suture  at  each  end,  the  avoid- 
ance of  all  tension,  strict  asepsis,  and  immediate  union  of  the 
wound  of  the  soft  parts. 

Subcutaneous  rufi'ure  of  a  nerve  is  rare,  but  is  occasionally 
met  with  as  the  result  of  a  severe  twist  or  wrench.  I  have  seen 
it  twice  in  the  peroneal  nerve  where  it  winds  round  the  head  of 
the  fibula.  It  is  attended  with  severe  pain  at  the  time  of  injury, 
perhaps  also  referred  to  the  periphery  of  the  nerve,  and  the 
gradual  foimation  of  a  bulbous  sweUing  on  the  nerve  immediately 
above  the  rupture.  The  same  effects  follow  as  in  division  of  a 
nerve  in  an  open  wound.     The  treatment  is  also  similar. 

In  the  evulsion  of  a  hmb  the  nerves  may  be  torn  away   from 
their  roots,  as  in  the  instance  of  a  boy  recently  in  St.  Bartholo- 
mew's Hospital,  whose  leg  was  torn  off  above  the  knee,  bringing 
with  it  the  whole  sciatic  nerve  as  far  as  its  origin  from  the    spinal  ■ 
cord. 


208  INJURIES   OF   SPECIAL   TISSUES. 

Compression  of  a  nerve  occasions  numbness  and  tingling,  and, 
if  severe  and  prolonged,  partial  or  complete  paralysis  of  the  parts 
supplied  by  it,  and  the  series  of  changes  described  in  the  last 
section.  As  examples  may  be  mentioned  crutch  palsy,  due  to  the 
pressure  of  a  crutch  upon  the  large  nerves  in  the  axilla  ;  the 
dropped  wrist,  from  the  involvement  of  the  musculo-spiral  nerve 
in  the  callus  in  fracture  of  the  humerus  ;  the  tingling,  numbness 
and  partial  paralysis  sometimes  following  dislocations  of  the 
shoulder  from  the  pressure  of  the  head  of  the  displaced  bone  on 
the  brachial  plexus ;  the  pain  c?.used  by  the  pressure  of  a  tumor 
on  a  nerve  ;  the  "  pins  and  needle'^.  "  felt  in  the  feet  after  sitting 
on  the  edge  of  a  chair  from  compression  of  the  sciatic  nerve,  etc. 
The  treatment  consists  in  releasing,  if  practicable,  the  nerve  from 
the  compressing  agent.  If  a  wound  of  the  soft  tissues  is  necessary 
to  accomplish  this  object,  healing  without  suppuration  should  be 
obtained,  if  possible,  as  otherwise  the  nerve  may  become  again 
compressed  by  the  resulting  scar-tissue. 

Contusions  of  nerves. — A  familiar  example  of  this  injury  is  a 
blow  on  the  ulnar  nerve,  as  it  lies  behind  the  internal  condyle. 
There  is  intense  pain  at  the  spot  struck,  and  shooting  pains  and 
"pins  and  needles"  in  the  parts  supplied  by  the  nerve.  These 
symptoms  pass  off  shortly,  but  occasionally  they  may  be  more 
severe  and  last  for  several  weeks,  in  which  case  there  is  probably 
some  effusion  of  blood  in  the  nerve.  In  rare  instances  ascending 
neuritis,  persistent  neuralgia,  or  even  paralysis,  and  changes 
similar  to  those  observed  after  complete  division  of  a  nerve,  may 
follow. 

Foreign  bodies  in  nerves. — A  portion  of  a  needle  broken  off 
in  a  nerve,  the  lodgment  of  small  shot  from  a  gun  accident,  etc., 
may  give  rise  to  inflammation  of  the  nerve,  persistent  irritation 
and  pain  at  the  injured  spot,  spasm  in  the  muscles,  and  pain  or 
tingling  in  the  parts  supplied  by  the  nerve.  Such  accidents  have 
occasionally  been  followed  by  epileptiform  convulsions.  The 
treatment  is  to  cut  down  upon  and  remove  the  foreign  body. 


DISEASES    OF    BONE.  2O9 


SECTION  IV. 

Diseases  of  Special  Tissues. 

diseases  of  bone. 

Diseases  or  Bone  may  be  classified  into  those  depending  upon 
— I.  Inflammation  and  its  results.  2.  Simple  defect  or  increase 
in  nutrition.     3.  Constitutional  dyscrasia  ;  and  4.  New  growths. 

I.  Inflammation  and  its  Results. 

Inflammation  of  bone. — In  studying  inflammation  of  bone  it 
should  be  borne  in  mind  that  it  is  in  the  soft  parts  of  bone, — the 
periosteum,  the  medullary  membrane,  and  the  delicate  vascular 
connective  tissue  which  pervades  the  Haversian  canals  and 
cancelli,  that  the  inflammation  occurs,  and  that  the  pathological 
process,  though  somewhat  modified  by  the  hard  and  resisting 
nature  of  the  osseous  framework,  is  essentially  similar  to  that 
which  occurs  in  the  soft  tissues.  The  same  vascular  and  exuda- 
tive changes  ensue,  and  are  accompanied  by  the  like  phenomena 
of  redness,  heat,  pain  and  swelling.  The  inflammation,  moreover, 
may  be  of  a  simple  and  local,  or  of  a  diffuse  and  septic  or  in- 
fective character,  and  variously  influenced  by  such  constitutional 
states  as  syphihs,  struma,  gout,  and  rheumatism,  or  by  the  pres- 
ence of  miliary  tubercle.  Further,  it  may  terminate  in  resolution, 
or,  in  sclerosis,  caries,  necrosis,  or  suppuration,  conditions  com- 
parable to  fibroid  thickening,  ulceration,  gangrene  and  suppura- 
tion of  soft  parts.  On  account  of  the  intimate  connection  of  the 
bone  with  the  periosteum  and  medullary  membrane,  inflammation 
is  seldom  limited  to  any  of  these  structures,  and  when  one  is 
affected  the  others  generally  soon  become  also  involved.  Ac- 
cording, however,  as  the  inflammation  begins  in,  or  is  chiefly 
confined  to  the  periosteum,  medulla  or  bone,  the  disease  for  con- 
venience is  spoken  of  as  periostitis,  osteomyelitis,  and  osteitis. 

Periostiiis,  or  inflammation  beginning  in  or  chiefly  affecting 
the  periosteum,  may  be  acute  or  chronic. 

Acute  Periostitis  may  occur  (i)  as  a  simple  local,  or  (2)  as  a 
diffuse  and  infective  inflammation,  the  former  being  generally  the 
result  of  some  local  injury,  the  latter  of  some  severe  constitutional 
dyscrasia. 

Q* 


2IO  DISEASES    OF   SPECIAL   TISSUES. 

Acute  simple  periostitis  is  generally  the  result  of  a  local  injury, 
and  occurs  most  frequently  in  the  tibia,  that  bone  being  most  ex- 
posed to  injuries,  as  kicks,  blows,  etc.  Pathology. — The  inflam- 
mation is  of  the  ordinary,  simple  kind,  and  usually  terminates  in 
resolution  ;  occasionally,  however,  suppuration  occurs,  attended 
by  some  superficial  necrosis,  or  the  inflammation  may  become 
chronic.  Symptoms. — There  is  acute  throbbing  pain,  increased 
on  pressure,  and  worse  at  night.  If  the  bone  is  superficial,  as  in 
the  case  of  the  tibia,  there  may  be  also  local  redness  of  the  skin, 
oedema,  heat  and  evident  swelling  over  the  bone,  followed,  should 
suppuration  occur,  by  fluctuation.  Treatmeut. — Rest,  elevation 
of  the  part,  and  the  application  of  cold,  with  perhaps  a  few  leeches, 
will  usually  suffice;  but  should  suppuration  threaten,  hot  boracic 
poultices  should  be  put  on,  and  a  free  incision  made  as  soon  as 
pus  has  formed.     Opium  may  be  required  to  relieve  pain. 

Diffuse  infective  periostitis,  sometimes  known  as  "  acute  ne- 
crosis," is  always  of  a  grave  nature,  as  not  only  may  it  lead  to  the 
death  of  large  portions  of  bone,  but  it  may  also  terminate  fatally 
from  septicaemia  or  pyaemia. 

Cause. — It  generally  occurs  in  debilitated  children,  following 
upon  some  slight  injury,  as  a  blow  or  fall  upon  the  part.  It  is, 
however,  probable  that  it  depends  upon  some  constitutional  mis- 
chief, and  that  such  local  influences  as  injury,  cold,  etc.,  although 
they  may  act  as  slight  exciting  causes,  have  little  or  nothing  to 
do  with  it.  It  also  occurs  as  a  sequela  of  the  continued  fevers. 
From  the  constancy  with  which  micro-organisms  {staphylococci, 
streptococci)  have  been  found  in  the  pus,  it  is  now  generally  be- 
lieved to  depend,  chiefly  or  in  part,  in  some  way,  on  their  pres- 
ence in  the  system.  Pathology. — The  disease  appears  to  begin 
generally,  as  here  described,  as  an  acute  infective  inflammation 
of  the  periosteum  which  rapidly  spreads  through  the  bone  to  the 
medulla ;  but  some  believe  that  it  begins  in  the  medulla,  and 
thence  spreads  to  the  periosteum.  In  any  case  pus  is  rapidly 
formed  beneath  the  periosteum,  stripping  the  latter  from  the  bone, 
which,  thus  cut  off  from  its  nutrient  supply,  dies.  Sometimes  the 
whole  diaphysis  may  thus  perish.  The  epiphyses,  however,  gen- 
erally escape,  as  they  are  sup|;lied  by  a  separate  set  of  vessels, 
which,  as  long  as  the  epiphysial  caitilage  remains  unossified,  do 
not  anastomose  with  those  of  the  diaphysis.  For  the  like  reason 
the  joints  usually  escape,  but  as  the  periosteum  is  continuous  with 
their  capsular  ligament  the  inflammation  may  at  times  spread  to 
them  through  this  structure. 

Symptoms  and  diagnosis. — The  disease  is  attended  with  severe 
inflammatory  fever,  and  is  often  preceded  by  a  rigor,  and  some- 
times accompanied  by  delixium.     The  shafts  of  the  long  bones 


CHRONIC   PERIOSTITIS.  211 

are  most  frequently  attacked,  especially  the  lower  end  of  the 
femur,  the  tibia,  and  the  humerus.  The  nature  of  the  local  mis- 
chief may  not  at  first  be  recognized,  and  the  affection  may  be 
mistaken  for  acute  rheumatism,  but  the  deep-seated  intense  pain, 
which  becomes  agonizing  on  the  least  attempt  at  handhng,  soon 
makes  it  probable  that  the  periosteum  is  affected.  The  soft  parts 
covering  the  bone  become  swollen  and  oedematous,  the  skin 
white  and  waxy  looking,  and  later  dusky  red,  clearly  indicating 
the  presence  of  deep-seated  suppuration.  From  abscess,  how- 
ever, it  cannot  always  be  diagnosed,  except  by  an  exploratory 
incision  which  will  disclose  bare  bone.  Should  one  of  the  neigh- 
boring joints  become  involved  the  symptoms  become  more  urgent 
and  the  local  signs  of  acute  arthritis  supervene.  Signs  of  blood- 
poisoning  now  frequently  manifest  themselves,  and  the  patient 
may  rapidly  succumb  to  septicaemia  or  pycemia.  Should  recovery 
take  place  it  is  usually  with  the  loss  of  considerable  portions  of 
bone,  and  after  months  of  suffering,  or  it  may  be  with  a  stiff  joint 
or  the  loss  of  a  limb. 

Treatment. — Immediately  the  nature  of  the  disease  is  discov- 
ered a  free  incision  should  be  made  to  the  bone  under  the  strictest 
antiseptic  precautions,  and  the  wound  dressed  with  sal  alembroth 
gauze  or  similar  antiseptic  material.  x\bundant  fluid  nourishment, 
and  probably  stimulants,  will  be  required,  with  large  doses  of  qui- 
nine if  symptoms  of  blood-poisoning  supervene.  Should  a  joint 
become  involved  and  suppurate  it  must  be  laid  freely  open  and 
dressed  antiseptically ;  whilst  if  the  wound  leading  to  the  dead 
bone  becomes  septic,  and  signs  of  saprsemia  occur,  the  question 
of  amputation  must  be  raised.  The  necessity  of  an  early  incision 
cannot  be  too  strongly  insisted  upon,  as  by  its  means  extensive 
denudation  of  the  bone  and  necrosis  may  frequently  be  averted, 
and  the  risks  of  blood-poisoning  greatly  reduced.  Should  necro- 
sis occur,  the  dead  bone  will  have  to  be  removed  when  it  has  be- 
come loose.  Subperiosteal  resection  of  the  whole  of  a  diaphysis 
is  recommended  by  some  surgeons  as  a  means  of  preventing  or 
lessening  the  danger  of  blood-poisoning,  but  the  operation  does 
not  appear  to  have  met  with  much  favor.  During  the  last  year  I 
removed  the  whole  diaphysis  of  the  ulna,  with  the  result  that  all 
constitutional  symptoms  ceased  at  once  and  the  boy  made  an  ex- 
cellent recovery,  but  up  to  the  present  there  is  no  sign  of  the 
formation  of  new  bone. 

Chronic  periostitis  is  nearly  always  associated  with  some  amount 
of  inflammation  of  the  subjacent  bone,  and  is  generally  limited  in 
extent,  constituting  what  is  commonly  called  a  node.  Cause. — It 
is  mostly  due  to  syphilis,  but  may  be  of  rheumatic,  tuberculous,  or 
traumatic  origin,  or  caused  by  the  spread  of  inflammation  from  an 


212 


DISEASES   OF   SPECIAL   TISSUES. 


Fig.  59. 


ulcer  of  the  soft  parts.  It  sometimes  occurs  as  a  sequela  of  typhoid 
and  other  of  the  continued  fevers.  Pathology. — The  periosteum 
becomes  swollen  and  thickened  from  small-cell-infiltration  of  its 
deeper  layers,  whilst  a  similar  infiltration  occurs  in  the  Haversian 
canals  of  the  contiguous  bone.  The  inflammatory  material  may, 
under  appropriate  treatment,  be  absorbed  ;  or  it  may  undergo 
ossification,  or  more  rarely  break  down  into  pus  leading  to  caries 
or  sometimes  to  necrosis  of  the  subjacent  bone.  The  ossifying 
variety  (see  Fig.  59),  or  the  hard  node  as  it  is  called  when  cir- 
cumscribed in  extent,  is  more  common  in  the  long 
bones,  the  suppurating  or  soft  node  in  the  bones 
of  the  cranium.  A  suppurating  node  in  the  ex- 
tremities is  probably  always  of  tuberculous  origin; 
a  suppurating  node  on  the  cranium  is  generally 
syphilitic. 

Symptoms  and  diagnosis. — The  patient  com- 
monly complains  of  a  deep-seated,  dull,  boring 
pain,  worse  by  night  than  by  day.  On  examina- 
tion a  hard,  irregular  swelling  of  the  bone  is  felt, 
not  as  a  rule  very  painful  on  handling,  and  not 
accompanied  by  redness  of  the  skin.  On  the  head 
the  swell'ng  is  soft  and  fluctuating,  and  may  have 
to  be  diagnosed  from  an  abscess,  new  growth,  or 
sebaceous  cyst.  Its  evident  connection  with  the 
bone,  the  history  of  syphilis,  the  effect  of  treatment, 
and  if  still  in  doubt,  exploration  with  a  grooved 
needle,  will  clear  up  the  point. 

Treatment. — Iodide  of  potassium  is  useful  in  all 
forms  of  chronic  periostitis,  but  it  may  often  be 
necessary  to  give  it  in  large  doses.  In  the  syphi- 
litic variety  it  generally  acts  like  a  charm.  In  the 
rheumatic  an  ointment  containing  iodide  of  potassium,  mercury, 
and  belladonna  may  also  be  used  locally  with  benefit.  In  the 
tuberculous,  cod-liver  oil  and  syrup  of  the  iodide  of  iron  should 
be  given.  In  all  forms  opium  internally  is  indicated  when  there 
is  much  pain.  The  soft  node  on  the  cranium  should  on  no  ac- 
count be  opened,  even  where  the  skin  is  inflamed  and  appears 
about  to  give  way,  as  iodide  of  potassium  will  then  often  promote 
complete  resolution. 

OsTEO-MYEi.rris,  or  inflammation  beginning  in  or  chiefly  affect- 
ing the  medullary  membrane  and  cancellous  tissue  of  bone,  may 
like  periostitis  be  acute  or  chronic. 

Acute  osteo-mvelitis  may  also  occur  as  a  simple  localized  or  as 
a  diffuse  septic  or  infective  itifiamniation. 

Simple  acute  osteo-myelitis  is  generally  the  result  of  an  injury 


Chronic  periostitis. 
(From  St.  Bar- 
tholomew's Mu- 
seum.) 


DIFFUSE    INFECTIVE    OR    SEPTIC    OSTEO-IVIYELITIS. 


2T3 


Fig.  6o. 


exposing  the  medulla  as  a  compound  fracture,  or  the  sawing  of  a 
bone  in  amputation.  In  the  latter  instance  it  is  usually  quite 
local,  though  at  times  it  may  spread  a  slight  distance  up  the  bone 
and  cause  a  localized  central  necrosis.  The  sequestrum  in  such  a 
case  has  commonly  a  conical  form,  in  consequence  of  the  inflam- 
mation as  it  spreads  up  the  medullary  cavity  affecting  less  and 
less  of  the  surrounding  bone  lamellae.  Beyond  keeping  the  wound 
perfectly  aseptic  and  removing  the  sequestrum 
when  loose,  no  special  treatment  is  required. 

Diffuse  infective  or  septic  osteo-myelitis. — 
Cause. — This  variety  may  be  idiopathic  (infec- 
tive) or  traumatic  (septic)  in  origin.  The  idio- 
pathic variety,  like  acute  infective  periostitis, 
usually  occurs  in  young  and  either  debihtated  or 
strumous  subjects  without  apparent  cause,  and 
also  like  it  is  generally  believed  to  depend  upon 
the  presence  of  micro-organisms  {staphylococci, 
streptococci^  in  the  system.  Indeed,  as  already 
stated,  the  disease  described  as  infective  perios- 
titis is  believed  by  some  pathologists  always 
to  begin  as  an  infective  osteo-myelitis.  The 
traumatic  variety  appears  only  to  occur  as  the 
result  of  injury  to  the  interior  of  bone,  especially 
where  the  cancellous  tissue  is  exposed,  and  where 
the  wound  is  not  kept  aseptic.  Hence  it  is  most 
often  met  with  after  compound  fracture,  excisions, 
amputations,  and  the  operation  of  trephining  the 
skull. 

Pathology. — Whether  iodopathic  or  traumatic 
the  inflammation  rapidly  spreads  through  the 
bone  to  the  periosteum,  and  diffuse  suppuration 
ensues,  the  danger  of  sapraemia,  septicgemia,  and 
pyaemia  being  even  greater  than  in  diff"use  perios- 
titis, in  consequence  of  the  large  patulous  veins  of 
the  medulla  becoming  filled  with  purulent  and 
either  infective  or  septic  thrombi.  The  iodopathic  form  would 
appear  to  depend  upon  the  presence  of  infective  micro-organisms 
{staphylococci,  streptococci^  in  the  system ;  the  traumatic  usually 
on  these  micrococci  introduced  from  without,  and  hence  is  prob- 
ably preventable  if  the  wound  is  kept  strictly  aseptic.  Should 
the  patient  in  either  case  not  be  carried  off  in  a  few  days  by 
saprsemia,  septicaemia,  or  pyaemia,  the  whole  diaphysis  may  die,  or 
suppuration  occur  between  the  diaphysis  and  epiphyses,  and  de- 
struction of  the  neighboring  joints  ensue  (Fig.  60).  In  less  se- 
vere cases  the  medullary  membrane  may  become  thickened,  and 


Acute  osteo-mye- 
litis of  the  tibia, 
with  destruction 
of  the  knee  and 
anklejoints  (St. 
B  a  r  t  h  olomew's 
Hospital  Mu- 
seum.) 


214  DISEASES   OF   SPECIAL   TISSUES. 

• 

only  the  layers  of  bone  immediately  surrounding  it  may  die  {cen- 
tral ?iecrosis) . 

The  symptoms  of  the  idiopathic  form  are  similar  to  those  of  acute 
infective  periostitis  (see  p.  210),  save  that  at  first  there  may  be  less 
oedema  and  swelling  of  the  soft  parts  ;  but  soon  the  periosteum 
becomes  involved,  and  then  the  one  disease  can  hardly  be  distin- 
guished from  the  other.  The  septic  or  traumatic  variety  is  at- 
tended by  high  fever,  rigors,  and  swelling  and  oedema  of  the 
limb,  and  a  puffy  tumor  of  the  scalp  when  the  diploe  is  involved. 
In  the  case  of  an  amputation  the  wound  looks  imhealthy,  the 
flaps  separate,  and  the  periosteum  recedes,  leaving  the  end  of  the 
bone  exposed.  A  fungous  mass  of  granulations  generally  pro- 
trudes from  the  medulla  of  the  divided  bone. 

Treatment. — In  the  idiopathic  variety  an  early  and  free  in- 
cision through  the  periosteum  to  the  bone  should  be  at  once 
made.  In  traumatic  cases  every  effort  should  be  directed  towards 
rendering  the  wound  aseptic,  and  ensuring  an  efficient  drain.  Of 
late  considerable  success  appears  to  have  attended  the  scraping 
out  of  the  inflamed  medulla  from  the  affected  bone,  and  then  in- 
sufflating the  cavity  with  iodoform.  The  constitutional  treatment 
should  be  similar  to  that  described  under  acute  periostitis.  Should 
blood-poisoning  {saprcemia)  threaten,  the  question  of  amputation 
must  be  raised.  If  this  is  decided  on  it  should  be  done  through 
the  knee-,  elbow-,  or  shoulder-joints,  if  the  bones  of  the  leg,  fore- 
arm, or  arm  are  involved,  so  as  to  avoid  again  cutting  through 
cancellous  bone.  Amputation  at  the  hip-joint  is  in  itself  so  serious 
an  operation  that  it  is  an  open  question  whether  it  should  be 
undertaken  in  the  case  of  osteo-myelitis  of  the  femur.  The 
operation,  however,  is  less  dangerous  than  formerly,  and  as  it 
holds  out  the  only  chance,  its  propriety  should  cert.iinly  be  dis- 
cussed if  the  case  is  seen  early.  When  septicaemia  or  pyaemia  is 
already  fully  established  amputation  should  not  be  undertaken. 

Chronic  ostko  myelitis  can  hardly  be  distinguished  from 
chronic  osteitis.  Indeed,  in  chronic  inflammation  of  bone  the 
soft  tissues  lining  the  medulla,  cancellous  spaces,  and  Haversian 
canals  are  generally  equally  involved  in  the  process,  as  is  also 
frequently  the  periosteum.  At  times,  however,  the  inflammation 
may  be  more  or  less  limited  to  the  medullary  membrane,  and  to 
the  layers  of  bone  contiguous  to  it,  and  may  then  terminate  either 
in  central  necrosis,  or  in  ossification  and  the  consequent  oblitera- 
tion of  the  medullary  cavity  {osteo- sclerosis^. 

OsTEiTLS,  or  inflammation  of  the  bone  itself,  is  always  associated 
with  some  amount  of  inflammation  of  the  periosteum  and  of  the 
medullary  membrane,  and  hence  it  is  often  difficult  in  any  given 
pathological  specimen  to  determine  whether  it  is  one  primarily  of 


OSTEITIS.  215 

osteitis,  periostitis,  or  osteo-myelitis.  It  may  occur  in  any  bone, 
or  in  any  part  of  a  bone,  but  is  most  frequent  in  the  cancellous 
ends  of  the  long  bones,  in  the  cancellated  bones  of  the  tarsus  and 
carpus,  and  in  the  bodies  of  the  vertebrae.  The  term  osteitis  as 
here  employed  refers  to  a  chronic  or  subacute  inflammation  of 
bone,  acute  inflammation  of  bone  being  practically  indistinguish- 
able from  acute  osteo-myelitis  or  periostitis,  under  which  it  is 
included.  The  causes  may  be  predisposing  and  exciting.  Among 
the  former  may  be  mentioned  syphilis,  tubercle,  and  rheumatism  ; 
among  the  latter  any  local  injury,  and  exposure 
to  cold,  damp,  or  malarial  influences.  Fig.  61. 

Pathology. — As  in  inflammation  of  soft  parts, 
the  first  stage  of  osteitis  is  one  of  increased  vas- 
cularity, the  bone  appearing  red  and  injected 
from  dilatation  of  the  blood-vessels  in  the 
Haversian  canals.  Next,  exudation  and  escape 
of  leucocytes  take  place  into  the  dehcate  con- 
nective tissue  occupying  the  space  between  the 
blood  vessels  and  the  bony  walls  of  the  Haversian 
canals  and  cancelli  respectively,  and  the  cells  of 
the  connective  tissue  itself  also  undergo  prolifera- 
tion. The  earthy  salts  are  loosened  from  their 
connection  with  the  animal  matter,  and  the  bone 
lam.ellge  and  trabeculse  are  softened,  eaten  into  as 
it  were,  and  absorbed  by  the  pressure  of  the  in-  ]^ 
flammatory  material  which  here,  as  elsewhere, 
assumes  the  form  of  a  small-cell-exudation 
{granulation-tissue^.  The  bone  is  destroyed  Rarefvin° 
irregularly,  appearmg  crescentically  eaten  out  (St.'  Banhqio- 
into  spaces  known  as  Howship's  lacunce,  in  each  Kh!Ieuni.)°^^"^ 
of  which,  and  immediately  in  contact  with  the 
bone,  are  found  large  cells  {osteoclasts')  containing  many  nuclei. 
It  is  believed  that  these  osteoclasts,  which  are  in  some  way  de- 
rived from  the  inflammatory  exudation,  take  an  important  though 
unknov/n  part  in  the  absorption  of  the  bone.  The  bone- 
corpuscles  themselves  are  generally  thought  to  be  entirely  passive, 
and  to  take  no  part  in  the  rarefying  process.  In  this  way  the 
Haversian  canals  and  cancelli  become  dilated,  the  compact  bone 
being  thus  converted  into  cancellous,  and  the  cancellous  further 
widened  out  (see  Fig.  61).  The  periosteum  and  medullary 
membrane  generally  appear  thickened.  In  inflamixiation  of  bone, 
as  in  inflammation  of  the  soft  tissues,  several  terminations  may 
occur.  Thus,  resolution  may  take  place,  and  the  bone  resume 
more  or  less  its  normal  appearance  ;  or  the  inflammatory  material 
may  undergo  ossification,  and  the  bone  beome  hard  and  indurated 


osteitis. 


2i6  DISEASES   OF   SPECIAL   TISSUES. 

{osfeo-sclerosis  or  osteoplastic  osteitis),  a  change  comparable  to 
that  which  occurs  in  the  fibroid  thickening  of  the  soft  tissues  ;  or 
the  rarefying  process  may  continue  until  the  affected  portion  of 
bone  is  completely  destroyed  by  the  granulation-tissue  {rarefy- 
ing osteitis  or  caries),  a  termination  similar  to  ulceration  ;  or  if  the 
inflammation  is  more  acute,  the  vessels  in  the  Haversian  canals 
may  become  strangulated  by  the  pressure  of  the  inflammatory 
material,  and  the  inflamed  portion  of  bone  die  {necrosis),  a 
termination  of  like  nature  to  gangrene  of  the  soft  tissues;  or 
finally,  the  inflammatory  material  may  break  down  into  pus  {sup- 
pu ratio?}),  and  an  abscess  be  produced  in  a  way  similar  to  that 
which  occurs  in  the  soft  parts. 

Signs  and  diagnosis. — The  signs  vary  according  to  the  intensity 
of  the  inflammation,  and  are  similar  to  those  of  simple  periostitis, 
and  when,  as  is  frequently  the  case,  the  osteitis  is  associated  with 
inflammation  of  the  periosteum,  the  two  can  hardly  be  distin- 
guished. There  is  deep-seated  boring  pain,  worse  at  night  and 
increased  on  exercise,  perhaps  some  slight  oedema,  but  seldom 
any  redness  unless  the  periosteum  is  involved,  and  then  only 
when  the  bone  is  superficial.  There  is  at  first  no  swelling  of  the 
bone,  though  subsequently  it  may  become  perceptibly  enlarged. 
The  deep-seated  character  of  the  pain,  its  increase  and  long  con 
tinuance  after  percussion  of  the  bone,  with,  possibly,  relief  by 
steady  pressure,  and  the  absence  of  much,  if  of  any,  perceptible 
swelling,  point  to  osteitis ;  whereas  pain  of  a  more  superficial 
character  and  increased  on  pressure,  together  with  an  earlier  ap- 
pearance of  swelling,  indicates  periostitis.  From  chronic  abscess 
it  is  not  always  possible  to  diagnose  osteitis,  though  in  abscess  the 
pain  is  generally  more  localized,  and  a  slight  yielding  of  the  bone 
at  one  spot  may  be  discovered. 

Treatment. — Rest,  elevation  of  the  part,  a  few  leeches  in  the 
more  acute  forms,  the  administration  of  iodide  of  potassium  and 
in  some  instances  mercury,  the  application  of  small  blisters  from 
time  to  time  in  the  more  chronic  cases,  and  opiates  internally, 
with  opium  or  belladonna  liniments  externally  to  relieve  pain.  In 
obstinate  cases  linear  osteotomy,  which  consists  in  making  an  in- 
cision down  to  the  inflamed  bone,  and  continuing  it  into  the  bone 
substance  by  means  of  a  Hey's  saw  or  a  chisel,  will,  by  removing 
tension,  generally  give  permanent  relief  and  prevent  further 
changes  ensuing.  Should  the  existence  of  an  abscess  be  sus- 
pected, the  bone  may  be  drilled  in  several  directions  or  a  small 
trephine  applied.  Where  there  is  a  taint  of  gout,  struma  or 
rheumatism,  appropriate  remedies  for  these  affections  must,  of 
course,  be  given. 

Rarefying,  osieitis,  caries,  ok  ulceration  of  bone,  is  com- 


RAREFYING,  OSTEITIS,  CARIES,  OR   ULCERATION   OF   BONE.        217 


Fig.  62. 


parable  to  ulceration  of  the  soft  tissues,  and  is  characterized  by 
the  rarefaction,  molecular  death,  and  loss  of  substance  of  the 
bone-tissue,  and  the  tendency  of  the  inflammatory  exudation  to 
caseous  degeneration  and  suppuration. 

Cause. — Tubercle  and  syphilis  are  undoubtedly  the  most  fre- 
quent causes  of  caries.  Sometimes,  however,  caries  would  appear 
to  depend  on  a  debilitated  state  of  the  system,  in  which  there  is 
no  evidence  of  tubercle  or  syphilis,  and  to  which  the  terra  struma 
may  with  propriety  be  applied.  Occasionally  it  is  the  result  of  an 
injury. 

Pathology. — Caries,  as  has  already  been  stated,  is  one  of  the 
terminations  of  osteitis ;  indeed,  it  is  often  somewhat  difficult  to 
say  where  osteitis  ends  and  caries  begins.  In  caries  the  thinned 
and  eroded  trabeculje  of  the  inflamed  bone  become  still  further 
thinned  and  eroded  by  the  action  of  the  small-cell- exudation  and 
osteoclasts,  until  the  aff'ected  portion  of  the  bone  is  completely  de- 
stroyed and  replaced  by  granu- 
lation-tissue. Under  appropri- 
ate treatment  ossification  of  the 
granulation-tissue  may  occur ; 
more  often,  however,  especially 
in  tuberculous  cases,  the  in- 
flammatory material  undergoes 
caseation,  and  may  break  down 
into  pus  and  an  abscess  be 
formed,  which  may  remain  as 
such  in  the  interior  of  the  bone 
or  under  the  periosteum,  or 
later  may  open  externally,  giv- 
ing rise  to  a  sinus  leading  to  the 
disease.  In  other  cases  the 
small-cell-exudation  undergoes 
further  proliferation,  and  either 
makes  its  way  to  the  surface  of  the  bone  (Fig.  62),  and  thence 
through  the  soft  tissues  and  skin,  or  it  perforates  the  articular 
cartilage  and  enters  a  joint  {/ungating  caries).  At  other  times 
the  granulation-tissue  merely  destroys  the  bone  without  the  pro- 
duction of  pus  {dry  caries  or  caries  sicca)  ;  whilst  again  the  in- 
flamed bone  in  the  centre  of  the  area  may  die  en  masse  from  the 
cutting- off"  of  its  blood  supply,  and  become  separated  from  the 
surrounding  bone,  forming  a  sequestrum  at  the  centre  of  the 
carious  spot  {caries  necrotica).  In  tuberculous  cases  giant-cells 
and  the  tubercle  bacillus  have  been  discovered  in  the  inflamma- 
tory exudation.  The  favorite  seat  of  caries  is  the  cancellous 
tissue,  whereas  that  of  necrosis  is  the  compact.  Caries  is  most 
frequently  met  with  in  the  bodies  of  the  vertebrae,  in  the  cancel - 
10 


If^^^^ 


Diagram  of  caries.  A.  Granulation-tissue; 
B.  Small-cell-exudation  destroying  the 
bone:  c.  Small-cell-exudation  between 
vessels  and  walls  of  the  Haversian  canals; 
D.  Normal  bone. 


2l8  DISEASES   OF   SPECIAL  TISSUES. 

lous  ends  of  the  long  bones,  and  in  the  short  bones  of  the  tarsus 
and  carpus.  The  tubercuhir  variety,  to  which  many  restrict  the 
term  caries,  is  distinguished  by  the  more  maiked  tendency  of  the 
inflammatory  material  to  undergo  caseous  changes;  by  the  soft, 
greasy,  crumbling  condition  of  the  bone ;  by  the  more  extensive 
destruction  of  the  bone  ;  and  by  the  little  tendency  shown  towards 
the  formation  of  new  bone  and  repair. 

The  swiptoms  at  first  are  those  of  local  chronic  osteitis  and 
periostitis,  namely  some  pain,  with  oedema  and  swelling  of  the 
soft  parts  over  the  inflamed  bone  ;  but  soon  the  inflammatory 
products  make  their  vvay  to  the  surface,  and  a  sinus  or  sinuses 
leading  to  the  carious  bone  form.  The  sinuses  have  generally  a 
button  of  oedematous  granulations  at  their  entrance,  and  a  thin, 
purulent,  and  commonly  foul- smelling  discharge  containing  bone 
salts  in  solution  escapes  from  them.  On  probing  or  on  enlarging 
the  sinus  and  introducing  the  finger,  the  bone  is  felt  to  be  soft  and 
friable,  breaking  down  and  readily  bleeding.  Caries  of  the  verte- 
brae and  of  the  articular  ends  of  bone  will  be  described  under 
Diseases  of  the  Spine  and  Joints  respectively. 

The  treatment  will  necessarily  vary  according  to  the  situation 
of  the  disease.  When  accessible  the  carious  bone  may  be  gouged 
away.  In  doing  this  it  will  be  known  when  all  the  carious  bone 
is  removed  by  the  part  becoming  hard  to  the  gouge.  The  sinuses 
should  be  well  scraped  with  a  Volkmann's  spoon,  and  the  wound 
dressed  with  iodoform-glycerine  emulsions  and  iodoform  gauze. 
Unfortunately,  however,  after  the  carious  part  has  been  removed 
the  disease  may  recur  in  the  surrounding  bone,  so  that  in  caries 
of  the  tarsus  or  carpus  it  may  be  better  to  excise  the  whole  of  the 
affected  bone  or  bones,  or  where  the  caries  is  extensive,  to  am- 
putate the  foot  or  hand. 

NecrosIs  is  the  death  en  masse  of  the  whole  or  part  of  a  bone, 
and  is  analogous  to  gangrene  of  soft  parts.  It  is,  however,  of 
more  frequent  occurrence  than  gangrene,  inasmuch  as,  owing  to 
the  hard  and  resisting  nature  of  bone,  the  vessels  are  more  liable 
to  become  compressed  by  the  inflammatory  effusion,  and  the 
blood-supply  in  consequence  to  be  cut  off.  For  the  same  reason 
necrosis  is  more  common  in  compact  than  in  cancellous  bone  ; 
whilst  the  reverse  holds  good  with  regard  to  caries.  Hence, 
moreover,  necrosis  is  more  frequent  when  the  inflammation  is 
acute,  caries  when  it  is  less  acute,  as  in  the  latter  case  the  bone- 
trabeculoe  slowly  yield  anil  disintegrate  before  the  less  quickly- 
produced  inflammatory  exudation,  and  the  vessels  consequently 
esca])e  compression.  '1  he  bones  most  often  affected  are  the  tibia, 
the  femur,  the  lower  jaw,  the  bones  of  the  skull,  and  the  phalanges 
of  the  fingers. 


NECROSIS. 


2t9 


Fig.  63. 


Cause. — The  immediate  cause  of  necrosis,  like  gangrene,  can 
in  all  cases  be  traced  to  the  cutting  off  of  the  blood-supply  of  the 
bone,  and  this  again  may  be  due  to  inflammation,  injury,  or  more 
rarely,  as  in  the  necrosis  which  sometimes  occurs  in  old  people, 
to  some  change  in  the  vessels  probably  analogous  to  that  produc- 
ing senile  gangrene  of  soft  parts.  The  causes  of  inflammation  of 
bone  inay,  therefore,  also  be  looked  upon  as  causes  of  necrosis ; 
but  syphilis,  the  specific  fevers,  especially  scarlatina,  and  mercurial 
and  phosphorous  poisoning,  may  be  particularly  mentioned. 

Pathology. — In  injury,  the  death  of  the  bone  is 
due  to  the  stripping  off  of  the  periosteum,  the 
destruction  of  the  medullary  membrane,  or  more 
rarely  the  plugging  of  the  vessels  in  the  Haversian 
canals  with  cloth.  In  this  way  necrosis  may 
occur  after  compound  fracture,  or  in  stumps  after 
amputation ;  but  the  inflammation  that  follows 
the  injury  has  no  doubt  also  a  share  in  its  pro- 
duction. The  way  in  which  necrosis  is  brought 
about  in  inflammation  has  already  been  described 
under  periostitis,  osteitis,  and  osteo-myelitis,  and 
according  as  it  results  from  one  or  other  of  these 
causes  will  it  vary  in  its  situation  and  extent. 
Thus,  when  due  to  simple  periostitis  it  is  generally 
limited  to  the  external  lamellae  of  the  bone  {per- 
iphei-al  necrosis)  ;  when  to  simple  osteo-myelitis, 
to  the  layers  immediately  surrounding  the  med- 
ullary canal  {central  necrosis)  ;  when  to  diffuse, 
septic  or  infective  periostitis  or  osteo-myelitis,  it 
may  affect  the  whole  thickness  of  the  shaft  (Fig. 
63),  and  possibly  the  whole  diaphysis  {total 
necrosis)  ;  whilst  when  due  to  osteitis  it  is  usually 
associated  with  caries,  and  only  a  portion  of 
cancellous  tissue  perishes  {caries  necrotica). 

Characters  of  dead  bone. — The  dead  bone, 
which  is  called  a  sequestrum  or  an  exfoliation, 
is  bloodless,  white,  hard,  dry  and  sonorous  when 
struck,  but  often  becomes  brown  or  black  w-hen  exposed  to  the 
air  and  the  action  of  the  discharges.  Its  free  surface  is  smooth 
and  even,  or  if  previously  inflamed,  rough  and  irregular ;  its 
margins  are  serrated  and  ragged  ;  and  its  previously  attached  sur- 
face is  rough  and  uneven.  It  is  heavy  when  sclerotic  changes 
have  occurred,  light  and  porous  when  associated  with  caries. 
Process  of  separation. — When  a  portion  of  bone  has  become  ne- 
crosed it  acts  as  a  foreign  body  and  nature  tries  to  cast  it  off. 
In  some  situations  she  is  successful,  in  others  she  f:nls,  and  if  not 


Necrosis  of  shaft  of 
tibia.  (Druitt's 
Surgery.) 


220 


DISEL^SES   OF    SPECIAL   TISSUES. 


-=rs„,„^:t:^. 

Diagram  of  the  process  of  separation  of  dead  bone.  c. 
Dead  bone;  i.  Inflamed  living  bone  with  formation  of 
granulation-tisfiie  where  it  is  in  contact  with  the  dead 
part;  a.  Healthy  living  bone. 


assisted  by  art  the  dead  bone  may  remain  as  a  lifelong  source  of 

irritation.     The  separa- 

FlG.  64. 

ce  z  c 


tion  of  dead  bone  is 
best  studied  in  superfi- 
cial situations,  as  in  the 
cranial  bones  (Fig.  65), 
where  its  process  can 
be  watched.  Here,  say, 
from  the  breaking  down 
of  a  syphilitic  node 
{syphilitic  pcriosiilis'),  a 
portion  of  bone  is  ex- 
posed and  dies.  This, 
acting  as  an  irritant, 
causes  the  bone  around 
to  become  inflamed 
(Fig.  64)  ;  rarefaction 
{ulceration^  ensues, and 
around  the  dead  portion  is  formed  a  groove,  which  gradually 
deepens  and  extends  beneath  the  dead  part  until  the  latter  is 
completely  cut  off  from  the  living,  and  if  not  removed  by  art 
simply  comes  away,  or  exfoliates,  as  it  is  technically  termed. 
The  cavity  left  becomes  filled  with 
granulations,  which  subsequently 
ossify,  and  so  restore  the  lost  part. 
In  situations,  as  in  the  tibia  (Fig. 
66),  where  the  periosteum  has  not 
been  destroyed,  ossification  of  this 
membrane  proceeds  at  the  same 
time  as  the  bone  is  being  separated. 
The  dead  bone  thus  becomes  sur- 
rounded on  all  sides  by  new  bone, 
and  lies  bathed  in  pus  in  a  cavity 
lined  with  granulations  (Fig.  67), 
and  though  loose,  is  thus  prevented 
from  being  cast  off.  It  is  then  said 
to  be  invagina/etl,  and  is  called  a 
seqtiestriim.  At  certain  spots  where 
the  periosteum  and  soft  tissues  have 
been  perforated  by  the  discharges 
from  the  inflamed  bone  making  their  way  to  the  surface,  ossi- 
fication does  not  occur,  and  these  apertures  thus  left  in  the 
casing  of  new  bone  are  called  cloaca;  ( P'igs.  66,  67,  68,  d).  In 
necrosis  of  the  popliteal  surface  of  the  femur,  where  the  peri 
osteum  is  very  thin,  and  is  merely  in  contact  with  the  loose  fat 


Fig.  65. 


Syphililic   necrosis  of  llic  skull.     (St. 
Iiartholoniew's  Hospital  Museum.) 


NECROSIS. 


and  cellular  tissue  of  the  popliteal  space,  the  periosteum  is  usually 
destroyed  and  no  osseous  sheath  is  formed,  the  dead  bone  then 
lying  in  contact  with  the  popliteal  artery.  In  this  situation, 
moreover,  the  necrosis  is  usually  limited  to  the  triangular  popliteal 
surface  of  the  bone,  the  firm  attachment  of  the  fibrous  intermus- 


FiG.  66. 


Figs.  66,  67,  and  68  illustrate  the  formation  of  a  sequestrum,  its  separation  from  the  living 
bone,  and  the  cavity  left  alter  its  removal,  n.  Dead  bone:  b.  Living  bone;  c.  The  sepa- 
rated periosteum  lined  by  granulations;  d.  Cloacae  lined  by  granulations,  which  are  indi- 
cated by  shading,  and  are  continuous  with  those  lining  the  cavity  containing  the  sequestrum; 
f.  New  periosteal  bone  perforated  by  cloacse;  f.  Cavity  left  after  removal  of  the  dead  bone. 
(After  Billroth.) 


cular  septa  to  the  ridges  in  the  femur  on  each  side  of  this  surface 
preventing  the  further  separation  of  the  periosteum  and  conse- 
quent death  of  more  bone.  After  th'e  removal  of  the  sequestrum 
the  cavity  (Fig.  68,  /)  fills  with  granulations,  though  more  slowly 
than  after  the  removal  of  an  exfoliation. 

Symptoms. — These  vary  according  to  the  cause,  stage  and  situa- 
tion of  the  necrosis.  When  of  inflammatory  origin  the  symptoms 
at  first  will  be  these,  already  described,  of  periostitis,  osteo- 
myelitis or  osteitis,  according  as  one  or  the  other  of  these  has 
produced  it.  When  suppuration  has  occurred  and  an  incision 
has  been  made  to  the  dead  bone,  or  the  discharges  have  made 
their  way  to  the  surface,  or  the  wound,  in  the  case  of  an  injury, 
leading  to  the  dead  bone  has  remained  open,  a  sinus  or  sinuses 
will  exist.  These  generally  discharge  a  thick  foul-smelling  pus, 
and  are  accompanied  by  much  thickening  of  the  bone,  and  red- 
ness and  brawniness  in  some  instances  of  the  surrounding  skin. 
On  passing  a  probe  the  dead  bone  will  probably  be  felt.  In  trau- 
matic cases  there  will  further  be  the  history  of  the  injury.     Having 


222  DISEASES    OF   SPECIAL   TISSUES. 

discovered  dead  bone,  the  next  point  to  ascertain  is  if  it  be  loose. 
This  may  be  done  by  observing  if  it  can  be  moved  by  a  probe,  or, 
if  two  sinuses  exist,  by  passing  a  probe  down  each  and  pressing 
alternately  first  in  the  one,  then  in  the  other.  If  the  sequestrum 
is  loose,  a  see-saw  motion  may  thus  be  given  to  it.  In  superficial 
situations  such  as  the  cranium,  or  where  a  bone  protrudes  or  is 
exposed,  as  in  a  stump  or  compound  fracture,  the  dead  bone  will 
at  once  be  known  by  the  characters  already  given  (page  199). 
The  chief  distinctive  signs  bet'cveen  necrosis  and  caries  are  : — In 
necrosis  the  dead  bone  is  generally  hard  and  smooth,  in  caries 
soft,  rough,  and  crumbling ;  in  necrosis  the  granulations  around 
the  sinus  are  healthy  and  the  skin  is  generally  normal ;  in 
caries  there  may  be  no  granulations,  or  if  present  they  may  be 
oedematous,  and  the  skin  around  is  undermined  or  inflamed  ;  in 
necrosis  the  discharge  is  thick  and  yellow,  in  caries  thin  and 
watery ;  in  necrosis  there  may  be  great  thickening  of  the 
bone,  in  caries  there  is  usually  but  little.  It  must  not  be  for- 
gotten, however,  that  caries  may  be  associated  with  necrosis. 
In  some  cases  of  necrosis  no  suppuration  occurs  {quiet  necrosis^, 
but  the  bone  becomes  greatly  swelled  from  the  excessive  forma- 
tion of  new  bone  around  the  dead  portion.  It  then  closely 
resembles  a  new  growth,  from  which  it  may  be  impossible  in  some 
instances  to  distinguish  it  without  an  exploratory  incision  (see 
Tumors  of  Bones). 

Treatment. — The  dead  bone  should  be  removed  as  soon  as  it  is 
loose.  When  it  is  superficial  this  can  easily  be  done  by  the 
forceps,  after  slightly  enlarging  if  necessary  the  sinus  through  the 
soft  tissues,  or  where  the  end  of  the  sequestrum  is  exposed  in  a 
stump  by  simply  drawing  it  out.  But  where  the  dead  bone  is  in- 
vaginated  and  cloacae  leading  to  it  are  small,  a  more  serious 
operation  is  required  {scquestrotoniy).  The  operation  is  much 
facilitated  by  the  use  of  an  Ksmarch's  bandage.  The  sinus  lead- 
ing to  the  most  convenient  cloaca  should  be  enlarged  by  a  simple 
incision  in  the  longitudinal  axis  of  the  limb,  the  sequestrum  siezed 
by  forceps,  and  if  practicable  drawn  out.  If  the  cloaca  is  too 
small  to  admit  of  this  it  must  be  enlarged,  or  two  cloacse,  if  pres- 
ent, may  he  laid  into  one  by  cutting  away  with  a  mallet  and  chisel, 
Hoffman's  forceps,  Hey's  saw,  gouge,  etc.,  the  intervening  portion 
of  the  sheath  of  new  bone.  No  more  of  the  ntw  bone,  however, 
than  is  absolutely  necessary  should  be  cut  away,  for  fear  of  weaken- 
ing the  limb.  For  the  same  reason  cloacae  should  be  enlarged 
in  the  longitudinal  axis  of  the  bone.  The  extraction  of  the 
sequestrum  may  often  be  aided  by  the  use  of  the  elevator,  or  by 
cutting  it  in  two  pieces  with  the  bone-scissors.  The  cavity 
should   then  be  sprinkled  with  iodo-form,  packed  with  iodoform 


SUPPURATION   AND   ABSCESS   IN   BONE. 


223 


or  sal  alembroth  gauze  to  prevent  bleeding,  and  the  wound  dressed 
with  gauze  impregnated  with  the  same  or  other  antiseptic  material. 
Whilst  the  cavity  is  healing,  which  when  large  it  may  take  many 
weeks  or  even  months  to  do,  the  patient's  strength  must  be  sup- 
ported by  tonics  and  a  generous  diet. 

At  times  the  sequestrum  is  so  intimately  interlocked  between  the 
old  and  the  new  bone  that  it  may  be  impossible  to  remove  it.  In 
popliteal  necrosis,  where  there  is  no  periosteal  sheath  and  the  dead 
bone  is  in  contact  with  the  popHteal  artery,  great  care  is  required  to 
prevent  injury  to  that  vessel.  The  incision  for  exposing  the  dead 
bone  should  be  made  either  on  the  outer  side  of  the  popliteal 
space,  or  cautiously  through  the  space  a  little  to  the  outer  side  of 
the  large  vessels.  In  some  cases,  where  the  patient's  powers  are 
flagging  from  long-continued  suppuration,  or  signs  of  lardaceous 
or  other  visceral  disease  are  manifesting  themselves,  amputatiop 
may  be  called  for. 

Suppuration  and  abscess  in  bone. — Diffuse  suppuration  in 
bone  has  already  been  described  a?  a  common  termination  of  dif- 
fuse osteo-myelitis  and  periostitis.  Circumscribed  suppuration  or 
abscess  is  generally  of  the  chronic  variety,  and,  as  already  stated, 
is  one  of  the  terminations  of  chronic  osteitis. 

Chronic  abscess  in  bone  is  most  common  in  the  cancellous  ends 
of  the  long  bones,  especially  in  the  upper  and  lower  end  of  the 
tibia  and  lower  end  of  the  femur,  but  is  oc- 
casionally met  with  in  other  bones. 

The  causes  especially  leading  to  the  ter- 
mination of  osteitis  in  abscess  are  thought  to 
be  the  presence  of  tubercle  or  of  micro- 
organisms, the  strumous  diathesis,  or  a 
feeble  state  of  health.  At  times  the  abscess 
can  be  apparently  traced  to  an  iniury. 

Pathology. — In  the  course  of  rarefying 
osteitis  the  bone-trabeculge  are  gradually 
destroyed,  and  their  place  is  taken  by  a 
small-cell-exudation,  which  now  assumes 
the  form  of  granulation-tissue. 

This  in  the  focus  of  the  inflamed  spot 
softens  and  breaks  down  into  pus,  whilst 
that  around  the  centrally-softened  spot  con- 
stitutes the  abscess  wall,  and  forms  to  the 
naked  eye  a  distinct  membrane  (Fig.  69) 
lining  the  bony  cavity  {pyogenic  membrane^. 
The  bone  around  the  absceos  generally  becomes  sclerosed  owing 
to  the  ossification  of  the  inflammatory  products,  whilst  Xi^'^'  bone  is 
formed  beneath  the  periosteum.     In  this  way,  as  the  abscess  en- 


FlG.  69. 


Abscess  in  end  of  tibia.  The 
pyogenic  membrane  is  well 
seen.  (From  St.  Bartholo- 
mew's Hospital  Museum.) 


2  24 


DISEASES   OF   SPECIAL   TISSUES. 


Fig.  70. 


Necrosed  cann-Uous  bone  in  abscess 
cavity.  (From  ^t.  Bartholomew's 
Hospital  Museum.) 


larges  at  the  expense  of  the  old  bone,  new  bone  is  continually 
formed  around,  and  hence  the  pus  seldom  makes  its  way  to  the 
surface  as  in  the  soft  parts.  As  the  abscess,  however,  approaches 
a  joint,  new  bone  is  not  formed  beneath  the  articular  cartilage, 

and  so  the  pus  on  reaching  the  car- 
tilage may  perforate  it  and  escape 
into  the  joint.  When  the  inflam- 
mation is  more  acute,  suppuration 
may  occur  before  the  bone-trabe- 
cul^e  have  been  completely  de- 
stroyed, under  which  circumstance 
a  sequestrum  of  cancellous  tissue 
may  be  found  free  in  the  abscess 
cavity  (Fig.  70). 

I'he  symptoms  are  chronic,  and 
often  obscure.  Generally  there  is 
pain  of  a  dull,  boring,  and  localized 
character,  often  intermittent,  and 
worse  at  night ;  tenderness  on  pres- 
sure at  the  spot  where  the  abscess  is 
approaching  the  surface ;  some  oedema  and  pitting  of  the  soft 
tissues  ;  occasional  enlargement  of  the  end  of  the  bone  ;  and  later 
some  dusky  redness  of  the  skin.  Intermittent  attacks  of  inflam- 
mation of  a  neighboring  joint  without  other  apparent  cause  are 
very  suggestive  of  ab.scess.  These  symptoms  will  usually  serve 
to  diagnose  abscess  from  rheumatism,  local  periostitis,  and  a  new 
growth  in  the  end  of  the  bone.  From  chronic  osteitis  it  cannot 
always  be  distinguished  ;  but  this  is  not  of  so  much  importance, 
as  the  treatment  is  practically  the  same. 

Treatment. — An  Ksmarch's  bandage  having  been  apjjlied,  a 
crucial  or  T-shaped  incision  should  be  made  over  the  tender  spot, 
and  the  bone  trephined.  If  the  pus  does  not  escape,  a  perforator 
should  be  thrust  in  various  directions  into  the  cancellous  tissue  in 
the  hope  of  discovering  it.  The  abscess-cavity,  after  having  been 
well  scraped,  should  be  moj^ped  out  with  caibolic  acid  or  chloride 
of  zinc,  and  dusted  with  iodoform,  and  the  .wound  dressed  with 
iodoform  or  other  antiseptic  gauze,  great  care  being  taken  to  keep 
it  aseptic.  Should  the  abscess  break  into  a  joint,  amputation  will 
probably  be  necessary. 


2.  Diseases  depending  upon  Simple  Defect  or  Increase  in  Nutri- 
tion of  Bone. 

Under  this  head  are  included  two  diseases  of  bone  in  which 
neither  inflammation  nor  such  constitutional  affection  as  syphilis 
or  struma  appear  to  take  a  part — Atrophy  and  Hypertrophy. 


TUBERCLE.  2  2  S 

Atrophy  of  bone  is  a  common  accompaniment  of  old  age.  It 
may  also  be  produced  by  pressure  and  disuse.  Thus  it  is  seen  in 
the  bodies  of  the  vertebrse  from  the  pressure  of  an  aneurysm  of 
the  aorta  or  a  tumor  in  the  mediastinum  ;  in  the  bones  of  a  lim.b 
from  disuse,  as  in  long-continued  joint-disease,  and  in  stumps 
after  amputation.  An  atrophied  bone  is  ahvays  decreased  in 
weight,  often  in  size ;  and  in  some  situations,  as  the  neck  of  the 
femur,  is  liable  to  fracture  on  slight  provocation.  Atrophy  is 
always  attended  with  more  or  less  fatty  degeneration. 

Hypertrophy  of  bone  is  an  overgrowth  of  bone  which  is  due 
merely  to  an  increase  of  nutrition,  and  not  to  any  inflammatory 
change.  It  is  generally  dependent  upon  excessive  functional 
activity  of  the  part,  the  bone  increasing  in  size  and  strength  com- 
mensurately  with  the  hypertrophy  of  the  muscles.  It  may  also 
occur  in  association  with  general  hypertrophy  of  the  tissues  in  the 
affection  known  as  congenital  hypertrophy.  It  must  be  distin- 
guished from  inflammatory  thickening  of  bone,  a  condition  to 
which  the  term  "hypertrophy"  is  sometimes,  though  incorrectly, 
applied. 

3.   Constihitional  Affectio7is  of  Bone. 

Under  this  head  are  included  Syphihtic  and  Tubercular  affec- 
tions of  bone.  Rickets,  Scurvy-rickets,  MoUities  Ossium  and 
Acromegaly. 

Syphilitic  affections  of  bone  are  common  both  in  acquired 
and  congenital  syphilis.  In  the  former  they  generally  occur  dur- 
ing the  tertiary  stages  of  the  affection,  either  as  gummatous  in- 
flammations of  the  periosteum  (nodes),  or  as  chronic  inflamma- 
tory thickenings  or  gummatous  infiltrations  of  the  bone  itself, 
leading  to  caries,  necrosis,  or  sclerosis.  For  a  full  account  of  the 
peculiarities  of  the  above  affections  when  due  to  syphilis  the  stu- 
dent is  referred  to  a  work  on  Pathology.  The  affections  of  the 
bones  in  congenital  syphilis  have  already  been  briefly  referred  to 
in  the  section  on  that  subject  (see  page  73). 

TuBEKCLE. — We  have  already  seen  that  many  of  the  inflamma- 
tory diseases  of  bone,  especially  some  forms  of  rarefying  osteitis 
or  caries,  are  attributed  to  the  presence  and  degeneration  of 
tubercle;  and  it  has  been  pointed  out  in  what  respects  the  affec- 
tions of  tubercular  origin  differ  from  those  of  a  simple  or  trau- 
matic nature.  Here  it  need  only  be  added  that  miliary  tubercles 
may  often  be  found  scattered  through  the  medulla  and  in  the 
cancellous  tissue  in  cases  of  acute  tuberculosis  ;  but  as  in  these 
cases  the  bone-affection  plays  but  a  secondary  part  and  cannot 
be  diagnosed  during  life,  nor  indeed  as  a  rule  gives  rise  to  any 
symptoms,  it  need  not  be  further  described. 


2  26  DISEASES    OF    SPECIAL    TISSUES. 

Rickets,  though  generally  described  under  Diseases  of  Bone,  is 
a  constitutional  affection  occurring  in  infancy  and  early  childhood. 
It  is  characterized  by  impaired  nutrition  and  arrest  of  develop- 
ment of  the  whole  body,  and  especially  by  the  softening  and  the 
resulting  deformity  of  the  bones. 

Causes. —  (i)  Malnutrition  produced  by  improper  food,  espec- 
ially an  excess  of  the  starchy  elements  during  infancy  ;  (2)  debil- 
ity of  the  mother  during  gestation  and  lactation  as  the  result  of 
excessive  child-bearing  or  over-suckling  ;  and  (3)  bad  hygiene, 
/.  e.,  want  of  fresh  air  and  sunshine,  residence  in  damp  dwellings, 
uncleanliness,  and  lack  of  attention  generally.  Struma  and  syphilis 
in  the  parent,  but  I  think  without  sufficient  evidence,  are  also 
given  by  some  as  causes. 

Pathology. — The  bone-changes  consist  essentially  in  the  forma- 
tion of  soft,  vascular,  imperfectly-ossified  bone,  which  replaces  the 
healthy  bone  as  the  latter  is  gradually  absorbed  in  the  normal 
process  of  development.  This  ill-formed  bone  is  produced  both 
at  the  line  of  the  epiphysis  and  under  the  periosteum,  /.  e.,  in 
those  situations  where  active  growth  normally  occurs.  In  the 
former  situation  the  intermediate  semi-transparent  bluish  zone 
of  ossifying  cartilage  between  the  diaphysis  and  epiphysis  is 
greatly  increased  in  thickness  and  its  line  of  junction  with  the 
bone  is  no  longer  straight  but  broken,  in  consequence  of  the 
irregular  advance  of  ossification.  The  adjacent  bone  is  soft  and 
spongy,  and  contains  here  and  there  islets  of  cartilage  which  have 
escaped  ossification,  whilst  its  medulla  is  abnormally  vascular.  It 
is  to  the  excessive  formation  of  this  proliferating  layer  of  cartilage 
and  ill  formed  bone  immediately  underlying  it  that  the  enlarge- 
ment of  the  ends  of  the  long  bones  and  the  beading  of  the  ribs  so 
characteristic  of  rickets  is  due.  Microscopically  the  cartilage- 
cells  in  the  bluish  zone  are  seen  enlarged,  and  instead  of  being 
arranged  in  regular  columns  are  grouped  irregularly ;  whilst  the 
calcification  of  the  matrix  between  them  is  also  seen  proceeding 
in  an  irri^gular  manner,  so  that  calcified  or  ossified  patches  exist 
here  and  there  vv'here  all  should  be  cartilage,  and  portions  of  car- 
tilage where  all  should  be  bone.  The  vascular  medullary  spaces 
which  are  continuous  with  these  channels  in  the  shaft  likewise 
project  in  an  irregular  manner  into  the  cartilage,  and  the  laminae 
of  bone  formed  from  the  osteoblasts  lining  these  spaces  are  defi- 
cient in  eaithy  salts.  Under  the  periosteum,  the  superficial  layers 
of  which  are  unaffected,  similar  soft  bone  is  laid  down  in  conse- 
quence of  the  osteoblastic  layer,  though  increased  in  thickness, 
producing  osteogenetic  fibres  deficient  in  earthy  salts.  Hence, 
whilst  all  the  bones  are  more  or  less  softened,  the  long  bones 
become  swollen  at  their  ends,  and  the  flat  bones  thickened,  espec- 


RICKETS. 


227 


ially  along  their  line  of  suture.  The  liver,  spleen  and  lymphatic 
glands  are  often  enlarged  from  irregular  increase  of  their  fibrous 
elements,  and  the  muscles  are  generally  soft,  flabby  and  wasted. 
Symptoms. — Rickets  is  most  frequently  met  with  between  the 
ages  of  eighteen  months  and  two  and  a  half  years.  Among  the 
early  symptoms  may  be  noticed  sweating  of  the  forehead  and 
perhaps  of  the  upper  part  of  the  body,  throwing  off  the  bedclothes 
from  a  desire  of  the  child  to  be  cool,  a  general  restlessness,  and 
often  an  excessive  tenderness  on  handling  and  aversion  to  move- 
ment. Sometimes  large  quantities  of  phosphate  of  lime  are  found 
in  the  urine.  The  abdomen  is  generally  enlarged,  and  there  is 
frequently  some  gastric  catarrh  and  flatulence.  The  swelling  of 
the  ends  of  the  long  bones,  especially  of  the  lower  end  of  the 
radius  and  tibia,  the  beading  of  the  ribs  where  they  join  the  carti- 
lages, and  the  thickening  of  the  cranial  bones  along  their  line  of 
suture  are  characteristic  of  the  disease.  Later,  bending  of  the 
bones  occurs.  Thus,  the  long  bones  generally  give  in  the  direc- 
tion of  their  normal  curves  and  near  the  epiphyses,  leading  to 
knock-knee,  bow-legs,  and  other  deformities.  The  yielding  of 
the  ribs  to  atmospheric  pressure  produces  the  deformity  known 
as  pigeon-breast.  The  spine  presents  a  general  curvature  with 
the  convexity  backwards  in  infants  and  young  children,  and  in 
older  children  a  lateral  or  a  lordotic  curve.  The  pelvis  is  ill  de- 
veloped, flattened  and  usually  of  a  reniform  or  hour-glass  shape, 
in  consequence  of  the  depression  of  the 
promontory  of  the  sacrum.  The  head  is 
square,  the  forehead  prominent,  and  the 
fontanelles  are  late  in  closing.  The  occip- 
ital bone  is  sometimes  thinned  so  that  it 
yields  on  pressure  or  it  may  be  in  places 
absorbed,  a  condition  known  as  cranio- 
iabes.  By  some  pathologists,  however,  this 
condition  is  believed  to  be  due  to  con- 
genital syphilis.  Dentition  is  generally 
delayed,  or  the  teeth,  if  cut,  often  soon 
decay  and  fall  out.  Bronchitis,  diarrhoea, 
convulsions,  laryngismus  stridulus  and 
chronic  hydrocephalus  are  not  infrequent 
complications ;  and  to  any  of  these,  but 
especially  to  the  first  two,  the  child  may 
succumb.  Under  appropriate  treatment 
the  disease  is  nearly  always  arrested,  and 
perfect  recovery  results.  The  bones,  how- 
ever, if  much  bent  are  liable  to  become  consolidated  in  the  de- 
formed condition,  and  premature  synostosis  of  the  diaphysis  and 


Fig. 


A  longitudinal  section  of  a 
rickety  femur.  (St.  Bar- 
tholomew's Hospital  Mu- 
seum.) 


22S  DISEASES   OF   SPECIAL   TISSUES. 

epiphysis  is  apt  to  occur,  inducing  a  stunted  growth.  Tlie  bones 
are  also  harder  and  denser  than  natural,  especially  on  the  side  of 
their  concavity,  where  a  thick  buttress-like  layer  of  dense  hard 
bone  is  formed.     (See  Fig.  71.) 

The  treattnejit  resolves  itself  into  proper  feeding  and  correct- 
ing bad  hygienic  conditions.  The  child  should  have  plenty  of 
new  milk  and  cream ;  and  the  juice  of  raw  or  underdone  meat,  or 
underdone  meat  that  has  been  pounded  up,  should  be  given  in 
quantities  suited  to  the  age  and  powers  of  assimilation.  Farina- 
ceous food  should  be  restricted  in  amount,  and  in  the  case  of 
infants  forbidden.  Abundance  of  fresh  air  and  sunlight  and  at- 
tention to  cleanliness  are  especially  indicated.  In  the  way  of 
medicine  cod-liver  oil  is  the  most  important,  and  may  almost  be 
looked  upon  as  a  specific.  It  should  be  combined  with  syrup  of 
the  phosphate  or  lacto-phosphate  of  iron  and  lime  in  half-drachm 
to  drachm  doses.  The  deformity  of  the  legs  may  be  corrected  in 
the  earlier  stages  by  insisting  upon  the  child  not  being  allowed  to 
stand  or  walk.  To  ensure  its  being  kept  off  its  legs,  splints  reach- 
ing from  the  waist  to  below  the  feet  may  be  applied.  Confirmed 
deformities  can  only  be  dealt  with  by  instruments  or  operation, 
which  will  be  described  under  bow-legs,  knock-knee,  osteoclasia, 
osteotomy,  etc. 

Scurvy- RiCKE'i s  is  an  acute  affection  of  young  children.  It  is 
also  known  as  aciile  rickets  and  as  infantile  scurvy.  The  disease 
is  characterized  by  a  sudden  swelling  in  connection  with  the 
bones,  and  especially  with  the  femur.  The  swelling  is  due  to  ex- 
travasation of  blood  beneath  the  periosteum.  The  ohxti  si^ns  are 
acute  tenderness,  oedema,  and  generally  a  spongy  condition  of  the 
gums.  'J'he  ireaUneni  consists  in  rest  and  in  the  use  of  such  con- 
stitutional remedies  as  are  appropriate  for  scurvy. 

MoLLiTiES  ossiuM  or  OsTEO-MALACiA  is  a  rare  disease,  character- 
ized by  softening  of  the  bones  through  the  re-absorption  of  their 
earthy  salts  and  destruction  of  their  osseous  lamellse. 

Cause. — It  is  a  di.sease  of  adult  life,  and  most  often  occurs  in 
females  during  the  child-bearing  period.  Sometimes  it  appears 
to  be  hereditary  ;  but  its  causation  is  practically  unknown. 

rath»/oi,'y. — The  disease  appears  to  begin  in  the  medullary 
tissue  of  bone,  which  is  replaced  by  a  soft,  dark-red  gelatinous 
material  somewhat  resembling  spleen-pulp,  whilst  later  the  whole 
bone,  with  the  exce])tion  of  a  thin  layer  immediately  beneath  the 
periosteum,  becomes  replaced  by  this  material  and  reduced  to 
little  more  than  a  mere  shell,  'i'he  bone  appears  first  to  become 
decalcified  and  then  destroyed.  The  exact  pathology  of  the  pro- 
cess is  not  known,  but  it  has  been  suggested  that  the  decalcifica 
tion  of  the  bone  is  due  to  the  action  of  lactic  acid,  which  has 


MOLLITIES   OSSIUM. 


229 


IMicroscopical  appearance  of  a  fragment  of 
bone  in  mollifies  ossium.  (From  Rind- 
fleisch.l 


been  found  both  in  the  bone  and  the  urine,  or  to  excess  of  car- 
bonic acid  in  the  veins  of  the  medulla,  which  are  said  in  the  early 
stages  to  be  enlarged.     The  microscopical  appearances  lend  some 
support   to   this   view,   as   in   a 
bone-trabecula  (see  Fig.  72)  the  P'°-  7^- 

decalcification  is  seen  to  begin 
around  the  Haversian  canals  and 
medullary  spaces,  the  bone- 
corpuscles  in  these  parts  having 
entirely  disappeared,  while  in  the 
centre  of  the  trabecula  they  are 
still  present.  At  times  the  gela- 
tinous material  is  in  places  yellow 
and  fatty-looking.  In  some  of 
the  specimens  in  St.  Bartholo- 
mew's Hospital  the  medulla 
appears  entirely  filled  with  fatty 

material ;  but  it  is  a  question  whether  these  specimens,  though 
called  mollities  ossium,  are  not  of  a  different  nature  from  the  dis- 
ease to  which  the  term  is  generally  applied,  and  do  not  rather 
depend  upon  a  senile  change. 

Symptoms. — In  the  early  stages  the  disease  may  be  mistaken 
for  rheumatism  or  neuralgia,  as,  beyond  some  general  feeling  of 
weakness  with  obscure  pains  in  the  bones,  it  is  attended  with  no 
definite  symptoms.  Suddenly,  however,  fracture  of  some  bone 
occurs,  whilst  others  become  bent  and  variously  distorted  without 
any  or  with  but  the  slightest  provocation.  Thus  the  pelvis, 
thorax,  spine,  and  extremities  become  misshapen  and  sometimes 
extraordinarily  deformed.  The  pelvis  is  flattened  from  side  to 
side,  the  symphysis  pubis  projects  in  the  form  of  a  beak,  giving  a 
rostrated  appearance  to  the  pelvic  inlet,  whilst  the  tuberosities 
are  approximated  and  the  pubic  arch  is  diminished  in  width. 
Thus,  parturition  is  rendered  difficult  if  not  impossible.  The 
condition  of  the  urine  is  an  important  element  in  the  diagnosis, 
a  peculiar  form  of  albumen  and  abnormal  quantities  of  phosphates 
and  lactic  acid  being  found  in  it.  The  disease  progresses  and 
the  patient  generally  dies  of  exhaustion,  or  during  parturition,  or 
of  dyspnoea  consequent  upon  respiratory  trouble  induced  by  the 
weakened  ribs.     In  a  few  cases  recovery  has  taken  place 

Treatment. — No  remedy  is  at  present  known  for  the  disease. 
The  strength  must  be  supported  by  tonics  and  abundance  of 
nourishing  food,  pain  must  be  relieved  by  opium,  and  rest  en- 
joined in  order  to  prevent  fracture.  The  patient  should  be 
warned  of  the  danger  of  child-bearing.  Should  she  be  already 
pregnant,   the   question  of  inducing  premature    labor  must   be 


230  DISEASES    OF   SPECIAL  TISSUES. 

raised  ;  whilst,  should  she  be  at  her  full  time,  craniotomy,  or  in 
advanced  deformity  of  the  pelvis,  Ceesarean  section  may  be 
necessary.  In  a  large  number  of  cases  of  late,  especially  in  the 
districts  on  the  Continent  where  the  disease  is  prevalent,  oopho- 
rectomy has  apparently  arrested  the  disease  and  the  bones  are 
said  to  have  again  become  firm. 

Acromegaly. — This  disease  is  characterized  by  a  symmetrical 
enlargement  of  the  bones  of  the  hands  and  feet  as  well  as  of  those 
of  the  head  and  face,  the  nasal  and  inferior  maxilla  being  chiefly 
affected.  The  disease  is  supposed  to  be  associated  with  changes 
in  the  pituitary  body,  but  at  the  best  is  at  present  little  under- 
stood. 

4.  New  Groiuths  in  Bone. 

New  GROWTHS. — Nearly  all  the  varieties  of  tumor  described  in 
the  section  on  that  subject  (p.  77)  occur  in  bone,  vSome,  indeed, 
as  the  exostoses,  are  altogether  confined  to  the  bony  tissue  ;  others 
occur  in  it  so  frequently  that  it  may  be  said  to  be  their  favorite 
seat ;  others,  again,  are  in  this  situation  so  rare  that  they  may  be 
dismissed  as  pathological  curiosities.  Some,  moreover,  the  carci- 
nomata,  only  occur  in  bone  as  secondary  growths,  the  primary 
malignant  tumors  of  bone,  formerly  described  as  carcinomata, 
being  now  classed  as  sarcomata. 

Tum.ors  of  bone  may  spring  from  the  periosteum,  the  medulla, 
or  the  bone  itself,  and  exhibit  a  remarkable  tendency  to  undergo 
calcification  or  ossification,  and  when  of  slow  growth  to  assume 
the  character  of  true  bone. 

OsTEOJMATA  OR  ossLous  TUJMORS  havc  the  structure  of  true  bone, 
and  are  only  met  with  in  connection  with  bone.  They  must  be 
distinguished  from  other  forms  of  tumor  that  have  undergone  cal- 
cification or  ossification.  They  may  be  divided  into  the  circum- 
scribed and  the  diffuse. 

Circumscribed  osseous  Untiors  or  exostoses  occur  in  two  chief 
forms,  the  cancellous  and  the  compact. 

{a)  The  cancellous  or  spongy  exostoses  consist  of  cancellous 
bone  containing  marrow  in  its  cancellous  spaces,  and  surrounded 
by  a  delicate  layer  of  compact  bone,  which  itself  is  covered  with 
a  capping  of  cartilage,  or  sometimes  merely  with  periosteum. 
They  are  most  frequently  met  with  in  the  young,  and  are  con- 
sidered by  some  to  be  ossifying  enchondromata  and  to  spring 
from  portions  of  the  epiphysial  cartilage  that  has  escaped  ossifica- 
tion. Their  common  situation  is  at  the  junction  of  the  diaphysis 
and  epiphysis  of  long  bones,  or  at  the  origin  or  insertion  of 
muscles — as  for  example,  the  inseition  of  the  adductor  magnus 
into  the  tubercle  just  above  the  internal  condyle  of  the  femur, 


NEW   GROWTHS.  23 1 

and  the  pectoralis  major  into  the  external  bicipital  ridge  of  the 
humerus.  They  are  also  very  com.mon  on  the  last  phalanx  of  the 
great  toe. 

{!?)  The  compact  or  ivory  exostoses  consist  of  dense,  hard  bone, 
which  usually  contains  no  Haversian  canals.  They  nearly  always 
spripg  from  the  bones  of  the  skull  and  face,  and  are  generally 
sessile  or  broadly  pedunculated,  and  of  a  lenticular  shape. 

Symptoms. — The  cancellous  variety  are  met  with  as  hard, 
smooth  or  irregular,  and  frequently  pedunculated  tumors  of  slow 
growth,  and  are  commonly  of  small  or  moderate  dimensions. 
Sometimes  they  are  quite  painless,  but  at  other  times  they  cause 
pain  on  movement  or  pressure,  as  is  the  case  with  the  small 
exostosis  which  so  frequently  grows  from  the  distal  end  of  the 
dorsal  surface  of  the  last  phalanx  of  the  great  toe.  This,  which 
is  usually  harder  than  the  more  common  form  of  cancellous 
exostosis,  but  less  hard  than  the  ivory,  occurs  as  a  tumor  project- 
ing under  the  nail,  and  raising  it  up  as  it  grows.  In  some  cases 
exostoses  affect  simultaneously  many  bones,  and  at  times  nearly 
all  the  bones  of  the  body.  They  are  then  generally  hereditary, 
and  often  symmetrical,  and  are  spoken  of  as  multiple  exostoses. 
They  have  the  structure  of  the  cancellous  form.  The  evident 
firm  attachment  of  the  ivory  exostoses  of  the  skull  to  the  bone, 
their  slow  growth,  small  size,  great  hardness,  the  freedom  with 
which  the  scalp  moves  over  them  and  the  absence  of  pain  and 
history  of  fracture  or  other  injury,  sufficiently  serve  to  distinguish 
them. 

Treatment. — A  spongy  exostosis,  unless  occasioning  pain,  de- 
formity, or  other  inconvenience,  or  growing  rapidly,  may  be  left 
alone  ;  otherwise,  it  should  be  removed  by  a  chisel,  bone-nippers, 
saw,  etc.,  taking  care  it  is  completely  extirpated,  as  what  is  left 
will  have  a  tendency  to  grow  again.  In  removing  an  exostosis 
from  near  the  knee-joint,  the  synovial  membrane  may  be  avoided 
by  flexing  the  knee,  and  so  drawing  the  membrane  away.  Ivory 
exostoses  should  not  as  a  rule  be  interfered  with,  as  they  are  so 
hard  that  no  ordinary  saw  will  cut  through  them,  and  the  skull 
has  been  fractured  in  attempts  to  remove  them  with  the  chisel. 
If  causing  great  inconvenience,  however,  it  is  probable  that  they 
might  be  safely  removed  by  the  rapidly-revolving  saw  of  the  sur- 
gical engine. 

Diffuse  osseous  tumors  occur  in  connection  with  the  bones  of 
the  face,  often  filling  up  the  antrum,  occluding  the  nasal  cham- 
bers, and  producing  much  deformity.  They  are  composed  of 
finely-cancellated  bone,  and  are  more  compact  than  the  can- 
cellous exostoses,  but  less  compact  than  the  ivory.  Their  slow 
growth,  extreme  and  uniform  hardness,  and  irregular  nodulated 


232 


DISEASES   OF   SPECIAL   TISSUES. 


Fig.  73. 


surface  will  serve  to  distinguish  them  from  sarcomata  undergoing 
ossification.  There  is  usually  little  or  nothing  that  can  be  done 
in  the  way  of  treatment.  The  superior  maxillary  bone,  however, 
has  at  times  been  confined  to  it  alone. 

Enchondromata  or  CARTILAGINOUS  TUMORS. — The  general  and 
microscopical  characters  of  these  growths  have  already  been  de- 
scribed under  Tumors  (p.  82).  In  the  bones  they  are  most 
frequently  met  with  in  the  fingers  (Fig.  73)  and  the  ends  of  the 
long  bones.  In  the  fingers,  where  they 
are  generally  multiple  and  often  con- 
genital, they  usually  begin  in  the  interior 
of  the  ends  of  the  phalanges  or  meta- 
carpal bones,  and  as  they  increase  in  size, 
expand  the  bone  around  them  into  a  thin 
shell,  which  may  finally  give  way,  allow- 
ing them  to  protrude.  When  growing 
from  the  articular  ends  of  long  bones, 
they  generally  spring  from  the  periosteum, 
and  thence  grow  both  outwards  and  in- 
wards, but  seldom  involve  the  articular 
surface.  They  are  thought  by  some  to 
possibly  arise  from  the  epiphysial  cartilage, 
especially  as  they  are  most  often  met  with 
in  the  young.  They  should  not  be  con- 
founded with  sarcomata,  in  which  con- 
siderable masses  of  cartilage  are  frequently 
developed,  or  with  the  exostoses,  which  are  often  capped  with 
cartilage,  and  are  regarded  by  some  as  ossifying  enchondromata. 
The  enchondromata  rarely  ossify,  but  may  undergo  calcification 
or  mucoid  softening,  and  when  unmixed  with  sarcomatous  ele- 
ments are  quite  innocent. 

Symptoms. — Their  slow  growth,  great  hardness,  evident  attach- 
ment to  the  bone,  the  absence  of  glandular  enlargement,  and 
non-implication  of  the  surrounding  tissues  and  skin  will  serve  for 
their  diagnosis.  When  of  large  size  ulceration  of  the  integuments 
covering  them  may  be  produced  by  their  pressure. 

Treatment. — If  small,  and  involving,  say,  only  one  finger,  they 
may  be  enucleated,  taking  care  not  to  injure  the  neighboring 
joint.  But  when  several  fingers  are  implicated,  and  the  hand  is 
rendered  useless,  aini)utation  of  the  affected  fingers,  or  of  the 
whole  hand,  may  be  necessary.  'I'he  removal  of  the  limb  is 
usually  called  for  when  they  grow  about  the  articular  end  of  a 
long  bone,  especially  if  they  have  attained  a  large  size. 

FiiJROMA'JA  OR  FIBROUS  'iUMORS  Hcldom  occur  in  bone  except  in 
the  jaws  or  in  connection  with  the  base  of  the  skull.     They  then 


Cartilaginous  tumors  of  the 
bones  of  the  hand.  (From 
iJruitt's  Surgery.) 


SARCOMATA. 


233 


Fig.  74. 


constitute  the  common  form  of  epulis  and  naso-pharyngeal  poly- 
pus respectively,  and  are  described  under  Diseases  of  the  Jaws 
and  Nose. 

LiPOMAiA  OR  FATTY  lUMORs  too  rarely  occur  in  bone  to  require 
special  mention.  I  have  seen  one  or  two  growing  from  the  outer 
surface  of  the  periosteum  {parosteal  lipoma).  They  were  not 
diagnosed  before  operation. 

Sarcomata  in  bone  may  be  divided  into  the  periosteal  and  the 
endosteal,  the  former  being  commonly  of  the  round-celled, 
spindle-celled,  or  mixed  variety,  the  latter 
of  the  myeloid  variety.  The  periosteal 
(Fig.  74)  spring  from  the  deep  layers  of 
the  periosteum,  and  as  they  increase  in 
size  invade  the  bones  beneath  on  the  one 
hand,  and  the  soft  tissues  surrounding 
them  on  the  other,  till  finally  the  skin  is 
involved,  and  they  protrude  as  a  fungous 
mass  if  the  patient  has  not  been  already 
carried  off  by  the  dissemination  of  the 
growth  through  internal  organs.  They 
are  very  prone  to  calcification  and  ossifi- 
cation, and  are  then  sometimes  spoken  of 
as  osteoid  sarcomata  ;  but  the  simple  ex- 
pression ossifying  sarcomata,  as  less  inis- 
leading,  and  as  more  indicative  of  what 
really  happens,  had  better  be  employed. 
Their  favorite  situations  are  the  neighbor- 
hood of  the  large  joints,  which,  however, 
they  seldom  involve.  Though  not  usually 
implicating  the  lymphatic  glands,  they 
often  rapidly  infect  the  system  through 
the  blood-stream  and  quickly  return  after 
removal.  The  endosteal  or  central  spring  from  the  medulla  in 
the  interior  of  the  bone,  and  are  of  slower  growth  and  generally 
less  mahgnant  than  the  periosteal.  As  they  increase  in  size  they 
expand  the  bone  around  them  into  a  thin  shell  (Fig.  75),  which 
finally  gives  way,  when  they  grow  with  greater  rapidity,  behaving 
as  the  periostea]  variety.  The  myeloid  form  of  the  endosteal 
sarcoma  is  the  least  mahgnant,  and  may  not  return  after  enuclea- 
tion or  complete  removal  for  several  or  many  years,  and  possibly 
not  at  all.  A  variety  called  parosteal,  in  which  the  sarcoma  in- 
volves the  outer  layers  only  of  periosteum,  has  been  described. 

Symptoms. — In  a  typical  case  oi periosteal  sarcoma  thtxe  will  be 
a  rapidly  growing  tumor,  evidently  connected  with  the  bone,  not  as 
a  rule  painfdl,  nor  usually  attended  with  heat,  oedema,  redness,  Or 
10* 


Periosteal  sarcoma  of  femur. 
(St.  Bartholomew's  Hos- 
pital Museum.) 


234  DISEASES    OF   SPECIAL   TISSUES. 

increase  of  body  temperature.  The  swelling  is  soft  and  semi- 
fluctuating  or  boggy,  sometimes  indistinguishable  by  touch  from 
an  abscess  ;  or  hard  in  some  parts,  soft  in  others,  or,  if  ossifying, 
uniformly  hard  all  over.  The  superficial  veins  may  be  tortuous 
and  dilated,  and  the  neighboring  lymphatic  glands  enlarged.  The 
patient,  who  is  usually  young,  frequently  complains  of  having  lost 

both  weight  and   strength,  al- 
^'°-  75-  though  till  later  there  may  be 

^ ^  "^  no  cachexia.     Often  there  is  a 

'^.  %!»      -^_  ,      -  -,,  distinct  history  of  the  growth 

having    appeared    some    time 
after  an  injury  of  the  part,  and 
IJ;;        it  is  probable  in  some  cases 
,  :^;        such  may  be  the  cause  of  the 
•  ;5         growth.     The  endosteal  axe.  oi 
!;'        much  slower  growth,  and  are 
.;  generally  accompanied  by  bor- 

' ^^^,:  ing   pain   whilst   the    bone   is 

■  /#  being    expanded.     Sooner   or 

■^J?£teJ^e^  l^ter   they  give  rise  to  a  more 

^'  or  less  uniform  swelling,  gener- 

■''  ally   of  the    articular   end    of 

Endosteal  sarcoma  in.  head  of   libia.     ^St.         Q^g  Qf   ^j^g  ]q,-,„   ^oneS,  and    aS 
Bartholomew  s  Hospital  Museum.;  ,      ,i         r     i  i 

the  shell  of  bone  becomes 
thinned  a  peculiar  sensation,  known  as  egg-shell  crackling,  may 
sometimes  be  felt  on  palpation.  After  they  have  protruded  from 
the  bone  they  present  similar  signs  to  the  periosteal,  and  at  times 
distinctly  pulsate,  especially  when  connected  with  the  pelvic 
bones.     They  may  then  be  mistaken  for  an  aneurysm. 

Diagnosis. — ^The  above  signs  will  commonly  serve  to  distinguish 
a  sarcoma  from  an  innocent  tumor  of  bone.  From  an  inflamma- 
tory affection,  such  as  subacute  periostitis  or  osteitis,  quiet 
necrosis,  or  an  abscess  in  the  interior  of  the  bone,  it  is  sometimes 
very  difficult  to  diagnose  a  sarcoma.  The  absence  of  signs  of 
inflammation,  or  increased  body  temperature,  of  oedema,  and  of 
pain  on  pressure,  point  strongly  to  the  swelling  being  of  a  sar- 
comatous nature.  But  these  signs  may  be  present  in  rapidly- 
growing  sarcomata,  and  may  be  but  faintly  marked,  or  not 
apparent,  in  inflammatory  affections.  A  steady  increase  of  the 
growth  whilst  under  observation,  notwithstanding  rest  and  appro- 
priate remedies  for  inflammation,  the  gradual  loss  of  weight  and 
strength,  and  the  unequal  consistency  and  irregular  surface  of  the 
swelling  are  more  certain  indications  of  its  malignancy ;  but 
puncture  with  a  grooved  needle,  or  even  an  exi)loratory  incision, 
may  be  required  before  the  nature  of  the  tumor  can  be  cleared 


CARCINOMA. 


235 


up.  From  an  aneur3'sm,  a  pulsating  sarcoma  may  be  very  diffi- 
cult to  distinguish,  especially  when  growing  from  the  pelvic  bones. 
In  the  tumor  the  pulsation  is  not  equally  expansile  over  all  parts, 
and  although  it  may  be  stopped  by  pressure  on  the  artery  above, 
the  tumor  does  not  become  smaller ;  nor  is  it  felt  to  refill  when 
the  pressure  is  removed  during  two  or  three  beats  of  the  heart,  as 
in  aneurysm  ;  and  a  bruit,  if  present,  is  not  so  distinct.  Portions 
of  expanded  bone,  moreover,  may  be  felt  in  parts  of  the  tumor, 
and  there  may  be  glandular  enlargement  and  other  general  signs 
of  malignancy.  From  an  inflammatory  condition  of  a  neighbor- 
ing joint  a  tumor  of  the  end  of  the  bone  may  generally  be  dis- 
tinguished by  the  absence  of  signs  of  inflammation  ;  by  the 
swelling  being  less  regular  in  contour  than  in  a  joint-affection,  and 
apparently  being  connected  more  intimately  with  one  of  the  bones 
entering  into  the  articulation  than  with  the  other ;  and  by  a  care- 
ful review  of  the  history  of  the  case. 

Treatment. — Periosteal  growths,  unless  the  glands  are  much 
enlarged  and  there  is  evidence  of  dissemination  having  occurred, 
call  for  amputation  of  the  limb,  or  removal,  if  practicable,  when 
growing  from  the  bones  of  the  head  or  trunk. 
Small  growths,  however,  may  at  times  be  dis- 
sected ofl"  the  shafts  of  the  long  bones,  and 
the  surface  of  the  bone  scraped,  gouged  away, 
or  destroyed  by  the  actual  cautery.  Endosteal 
growths,  if  small,  may  in  some  cases  be  enu- 
cleated, but  usually,  like  the  periosteal  variety, 
call  for  amputation.  In  some  situations,  as  in 
the  head  of  the  radius,  the  affected  portion  of 
bone  may  be  excised.  The  treatment  of  sar- 
comata of  the  jaws  and  of  other  special  regions 
is  described  under  Tumors  of  the  Jaws,  etc. 

Carcinoma  never  occurs  as  a  primary  growth 
in  bone.  It  may  spread  to  the  bone,  however, 
from  the  skin  or  mucous  membrane,  as  seen,  for 
example,  in  some  cases  of  squamous  carcinoma 
of  the  leg  or  lip,  or  be  deposited  there  in  the 
course  of  the  general  dissemination  following  on 
primary  carcinoma  of  other  tissues  or  organs,  as 
the  breast  or  liver.  In  the  latter  case  it  is 
seldom  discovered  till  after  death,  unless  it 
gives  rise  to  spontaneous  fracture  (Fig.  76). 
Treatment. — Where  epithelioma  has  spread  to 
the  bone,  free  and  early  removal  with  the 
knife  -before  the  glands  have  become  affected  is  the  only  treat- 
ment that  holds  out  a  prospect  of  success.     In  the  case  of  a  limb, 


Secondary  carcinoma 
of  the  shaft  of  the 
humerus  causing 
spontaneous  frac- 
ture of  the  bone. 
(St.  Bartholomew's 
Hospital  M  u  se  - 
um.) 


236  DISEASES   OF   SPECIAL   TISSUES. 

amputation  well  above  the  disease  is  generally  called  for,  although 
where  the  bone  is  but  little  involved  a  free  sweep  of  the  growth 
and  the  gouging  away  of  the  underlying  bone  may  under  some 
circumstances  be  justifiable.  Glands  that  have  become  affected 
should  be  removed  if  practicable. 

CvsTS  IN  BONE  are  rare,  except  in  the  jaws.  Hydatid  cysts  are 
occasionally  met  with,  but  require  no  special  description  (See  p. 
loi).  The  sanguineous  or  blood  cysts  formerly  described  were 
probably  sarcomatous  tumors  in  which  hemorrhage  had  taken 
place. 

Aneurysms  in  bone  are  occasionally  met  with,  and  vascular 
ERECTILE  TUMORS  Consisting  of  anastomosing  vessels,  and  some- 
what resembling  nsevi  of  the  soft  tissues,  at  times  occur  in  the 
bones  of  the  skull.  The  majority  of  pulsating  tumors  in  bone, 
however,  are  of  the  nature  of  soft  sarcomata. 

DISEASES    OF   JOINTS. 

Synovitis,  or  inflammation  of  the  synovial  membrane,  may  be 
acute,  subacute,  or  chronic. 

Acute  synovitis. —  Cause. — Generally  a  slight  injury,  as  a 
sprain  or  over-exertion  of  a  joint,  or  exposure  to  cold  and  wet  in 
a  gouty  or  rheumatic  subject.  Synovitis,  moreover,  especially  in 
the  knee,  often  occurs  during  an  attack  of  gonorrhoea,  and  is 
sometimes  seen  in  the  earlier  stages  of  syphilis.  It  is  well  known 
as  a  symptom  of  acute  rheumatism  and  pyaemia,  in  which  latter 
affection  rapid  suppuration  and  implication  of  the  other  tissues 
.  of  the  joint  occur. 

Pathology. — The  synovial  membrane  becomes  red  and  con- 
gested and  loses  its  lustre,  the  synovial  fringes  turgid,  and  the 
synovial  fluid  increased  in  quantity  and  slightly  turbid  from 
admixture  with  inflammatory  products.  Resolution  may  now 
occur,  or  the  inflammation  may  become  chronic,  or  it  may  spread 
to  the  cartilages,  bones,  etc.,  and  terminate  in  suppuration  and 
the  probable  disorganization  of  the  joint  (see  Acute  Arthritis). 

Signs. — The  joint  is  hot,  excessively  painful,  especially  on 
movement  and  pressure,  and  if  the  inflammation  is  very  intense, 
the  skin  may  be  slightly  reddened,  and  the  tissues  around  ocdem- 
atous.  The  joint  is  usually  held  flexed,  that  is,  with  the  capsule 
and  ligaments  relaxed — the  position  of  greatest  ease.  Where  the 
joint  is  superficial  the  swelling  is  well  marked,  the  outline  of  the 
synovial  membrane  being  distinctly  maj^ped  out.  Thus  in  the 
knee,  the  joint  perhaps  most  commonly  affected,  the  synovial 
membrane  can  l)e  seen  extending  u])wards  under  the  crureus  and 
jvasti,  and  bulging  on  either  side  of  the  ligamentum  patellar.  The 
patella  itself  is  raised  from  the  condyles  of  the  femur,  and  on 


CHRONIC   SYNOVITIS.  237 

making  pressure  on  it  the  fluid  is  displaced,  and  the  patella  can 
be  felt  to  strike  against  the  condyles  {riding  of  the  patella).  In 
the  elbow,  the  synovial  membrane  can  be  seen  extending  under 
the  triceps  and  on  either  side  of  the  olecranon ;  in  the  ankle, 
bulging  beneath  the  extensor  tendons  and  behind  the  malleoli. 
Feverish  symptoms  varying  in  intensity  according  to  the  severity 
of  the  inflammation  are  generally  present.  The  inflammation 
may  now  gradually  subside  or  assume  the  chronic  form.  Should, 
however,  suppuration  occur,  and  the  other  tissues  of  the  joint 
become  involved,  the  pain,  swelling,  and  oedema  increase,  and 
the  skin  becomes  of  a  dusky  red,  whilst  a  chill  or  distinct  rigor 
ushers  in  a  more  severe  type  of  inflammatory  fever. 

Treatjiient. — The  joint  should  be  placed  at  absolute  rest  on  a 
splint,  and  the  patient,  in  the  case  of  the  hip,  knee,  or  ankle,  con- 
fined to  bed.  In  applying  the  spHnt,  care  should  be  taken  that 
the  limb  is  in  the  position  best  suited  for  future  use  should  anky- 
losis ensue  ;  thus  the  knee  should  be  straight,  and  the  elbow  bent 
at  a  right  angle.  Where  the  joint  has  already  been  drawn  into  a 
faulty  position,  this  must  be  rectified,  the  patient  being  placed 
under  an  anaesthetic,  as  the  manipulation  is  attended  with  intense 
pain.  Cold,  by  means  of  evaporating  lotions  or  Leiter's  tubes, 
may  in  shghter  cases  be  applied  to  the  joint.  When,  however,  the 
inflammation  is  very  acute,  half-a-dozen  leeches  followed  by  hot 
applications  should  be  substituted  for  the  cold,  with  liniments  of 
belladonna  and  opium  to  assuage  pain.  Where  there  is  much 
distension  and  the  synovial  membrane  threatens  to  give  way,  the 
joint  should  be  aspirated  and  elastic  pressure  applied,  or  if  sup- 
puration occurs,  laid  freely  open  and  drained  antiseptically. 
Amputation  may  be  called  for  should  the  patient's  powers  fail 
under  the  long-continued  suppuration  that  at  times  ensues. 

Subacute  synovitis. — The  term  subacute  is  applied  to  less 
severe  cases  of  acute  synovitis.  But  as  one  form  of  the  disease 
differs  from  the  other  in  degree  rather  than  in  kind,  and  as  the 
causes,  symptoms,  and  treatment  are  similar,  no  special  descrip- 
tion is  required. 

Chronic  synovitis. —  Causes. — Similar  to  those  of  the  acute 
form,  of  which  it  is  often  a  sequel.  When  occurring  in  strumous 
subjects,  it  probably  nearly  always  depends  on  the  presence  of  the 
tubercle  bacillus,  and  will  be  described  under  tubercular  disease 
of  the  joints. 

Fathologv. — The  synovial  membrane  is  slightly  thickened,  and 
the  synovial  fluid  increased  in  quantity ;  but  there  is  little  or  no 
change  in  the  cartilages  or  the  other  tissues,  though,  if  the  disease 
is  neglected,  it  may  run  on  to  total  disorganizatioji  of  the  joint. 
At  times,-  the  synovial  membxane  becomes  greatly  distended  with 


238 


DISEASES   OF   SPECIAL   TISSUES. 


clear  serous  fluid,  a  condition  known  as  hydrops  arliciili,  and  in 
this  state  it  may  remain  for  years  without  any  further  change  en- 
suing ;  or,  after  long  periods,  the  synovial  membrane  may  become 
thickened,  and  little  masses  of  cartilage  form  in  its  hypertrophied 
fringes.  In  other  instances  pouch-like  protrusions  of  the  synovial 
membrane  may  extend  along  the  muscles  and  other  tissues,  often 
to  some  distance  from  the  joint,  where  they  give  rise  to  bursa- 
like-swellings  {Mo rraiii  Baker's  cysts). 

Signs. — The  joint,  as  in  the  acute  affection,  is  swollen,  and  the 
synovial  membrane  slightly  thickened  ;  but  there  is  little  or  no 
heat,  there  may  be  no  pain,  and  the  skin  is  unaltered  in  appear- 


FlG.  77. 


Fig.  78. 


Fig. 


Thomas's  hip-joint 
splint  (front  view) 
with  pattern. 


Thomas's  hip-joint  splint  ap- 
plied. Fatten  on  sound  limb. 
(Heath's  Minor  Surgery.) 


Thomas's  knee-joint  splint  with 
foot-piece  for  extension. 
(Heath's  Minor  Surgery.) 


ance.  The  patient,  however,  complains  that  the  joint  feels  weak 
and  stiff  on  movement,  but  he  does  not  suffer  from  starting-pains 
at  nights.  In  hydrops  articidi  the  synovial  membrane  is  greatly 
distended  but  not  thickened,  and  save  a  sensation  of  weakness 
and  want  of  security  in  the  joint  on  walking,  the  affection  gives 
no  trouble.  In  what  may  be  termed  the  /^//;-.vfl!/^'^?;7>/r  of  chronic 
synovitis,  in  addition  to  the  joint-affection,  more  or  less  tense, 
fluctuating  and  translucent  swellings  occur  in  the  neighborhood 
of  the  joint.     On  pressure,  these  swellings  become  less  tense 


TREATMENT   OF   CHRONIC   SYNOVITIS. 


239 


Fig.  80. 


and  some  of  the  fluid  contained  in  them  can  at  times  be  forced 
back  into  the  joint. 

Treatment. — The  indications  are  ( i )  to  prevent  further  irrita- 
tion by  placing  the  joint  at  perfect  rest,  (2)  to  promote  the  ab- 
sorption of  the  inflammatory  products  by  pressure  and  counter- 
irritation,  and  (3)  to  remove  any  stiffness  that  may  remain  on  the 
subsidence  of  the  inflammation  by  passive  movements,  massage, 
or  the  breaking  down  of  fibrous  adhesions.  Thus,  the  joint  should 
be  fixed  in  an  accurately-fitting  poroplastic  or  a  moulded  leather 
splint,  or  a  plaster-of-Paris  bandage  ;  and  the  limb,  if  a  joint  of 
the  upper  extremity  is  affected,  should  be  carried  in  a  sling.  In 
the  case  of  the  lower  extremity,  the  patient,  if 
unable  to  lie  up,  may  wear  a  Thomas's  hip  or 
knee  splint,  according  to  the  joint  affected,  and 
be  allowed  to  get  about  on  crutches  with  a  pat- 
ten fixed  to  the  boot  of  the  sound  limb  (Figs. 
77,  78,  79  and  80).  Pressure  may  be  applied 
by  strapping  the  joint  with  ammoniacum  and 
mercury  plaster,  or  with  Scott's  dressing,  or  by 
means  of  a  Martin's  bandage.  Counter-irrita- 
tion may  be  affected  either  with  the  liniment  of 
iodine,  small  flying  blisters,  or  the  actual  cau- 
tery. Rest,  however,  though  most  essential  in 
the  treatment,  should  not  be  continued  too  long, 
lest  the  joint  become  stiff.  Should  this  happen, 
friction,  massage,  and  passive  movements  must 
be  sedulously  used,  or  if  all  signs  of  inflamma- 
tion have  ceased,  the  adhesions  may  be  broken 
down  under  an  anaesthetic.  In  the  meantime, 
the  patient's  general  health  must  not  be  ne- 
glected, and  any  constitutional  tendency  to 
gout,  rheumatism,  etc.,  should  be  corrected  by 
appropriate  remedies.  During  convalescence  a 
stay  at  Buxton,  Harrogate,  Wiesbaden,  or  some 
other  suitable  spa  may  be  of  benefit.  In  hydrops 
artiaiU  the  treatment  recommended  above  may 
first  be  perseveringly  tried.  After  prolonged  rest 
has  failed,  massage  of  the  limb  with  exercise  of  the  joint  may 
sometimes  affect  the  absorption  of  the  fluid  ;  this  failing,  the  joint 
may  be  aspirated  and  pressure  re-applied.  Should  it  refill,  it  may 
be  injected  with  iodine,  or  in  very  severe  cases  laid  open,  well 
washed  out,  and  drained.  Where  cysts  have  formed  in  the 
neighborhood  of  the  joint,  they  should,  if  pressure  fails  to  cure 
them,  be  left  alone  or  dissected  out  and  neck  tied.  It  is  not  safe 
to  puncture  them,  for  fear  of  setting  up  suppuration  in  the  joint, 


Thomas's  knee-joint 
splint  applied.  Pat- 
ten on  sound  limb. 
(Heath's  Minor 
Surgery.) 


240 


DISEASES   OF   SPECIAL   TISSUES. 


and  even  a  free  incision,  with  antiseptic  precautions,  is  not  devoid 
of  risk. 

Acute  arthritis  is  the  term  appHed  to  a  general  inflammation 
of  all  the  tissues  of  a  joint.  It  may  begin  in  the  synovial  mem- 
brane, in  the  articular  ends  of  the  bones,  or  in  the  tissues  around, 
but  in  whatever  way  it  begins,  the  whole  joint  rapidly  becomes 
involved  in  the  inflammatory  process. 

The  cai/ses  are  very  various,  and  include  those  given  under 
acute  synovitis.  Among  the  most  frequent  causes,  however,  may 
be  mentioned  penetrating  wounds,  infective  periostitis  or  osteo- 
myelitis, epiphysitis,  the  bursting  of  an  abscess  in  the  soft  parts  or 
in  the  end  of  the  bone  into  the  joint,  pyaemia,  and  the  continued 
and  the  exanthematous  fevers. 

Pathology. — The  course  of  the  disease  differs  somewhat  accord- 
ing to  its  cause  and  mode  of  ori- 
FiG.  81.  gin.    In  a  typical  case  beginning 

in  the  synovial  membrane  and 
running  on  to  complete  disor- 
ganization of  the  joint  and  sub- 
sequent ankylosis  the  following 
changes  occur  : — The  inflamma- 
tion rapidly  spreads  from  the 
synovial  membrane  to  the  bones 
and  surrounding  soft  tisi;ues ;  the 
cartilages  are  destroyed  ;  the  lig- 
aments are  softened  ;  the  articu- 
lar surfaces  are  displaced  by  the 
action  of  the  muscles ;  and  the 
joint  is  converted  into  the  cavity 
of  an  abscess  (Fig.  81).  The 
capsule  of  the  joint  now  gives 
way,  allowing  the  inflammatory 
product  to  escape.  The  soft  tis- 
sues break  down  into  pus,  and 
the  abscesses  open  externally,  forming  sinuses  leading  down  to  the 
joint.  Should  the  inflammation  now  subside,  granulations  spring 
up  from  the  denuded  ends  of  the  bones,  the  two  layers  of  granu- 
lations unite,  and  after  passing  through  a  fibrous  stage  undergo 
ossification  {l^ony  ankylosis),  leaving  the  patient  with  a  stiff  joint. 
The  pathological  process  by  which  these  changes  are  brought 
about  is  as  follows  :  The  synovial  membrane,  which  at  first  ap- 
pears red  and  injected,  rapidly  becomes  infillratcd  with  inflam- 
matory products,  and  is  converted,  together  with  the  adjacent 
capsules,  into  a  tliick  layer  of  granulation-tissue.  I'he  inflamed 
articular  ends  of  the  bones  also  become  infiltrated  witli  inflamma- 


Acute  arthritis  of  the  knee-joint  beginning 
in  the  synovial  membrane.  The  lig.'i- 
ments  arc  ahnost  destroyed  and  the  tibia 
is  displaced  backwards  and  outwards. 
The  joint  was  filled  with  pus.  (.St.  Bar- 
tholomew's Hospital  Museum. J 


ACUTE   ARTHRITIS.  24 1 

tory  products  and  pass  through  the  changes  described  under  rare- 
fying osteitis.  The  cartilages  thus  cut  off  from  their  nutrient 
supply  lose  their  lustre,  and  while  portions  die  and  are  cast  off 
into  the  interior  of  the  joint,  the  rest  is  invaded  both  on  its  free 
and  deep  surface  by  the  granulations  derived  from  the  synovial 
membrane  on  the  one  hand,  and  from  the  articular  end  of  the 
bone  on  the  other.  As  the  result  of  this  invasion,  the  cartilagin- 
ous matrix  liquefies,  and  the  cartilage  cells  proliferate,  while  the 
brood  of  young  cells  thus  formed  in  part  coalesce  with  the  cells 
of  the  invading  granulation-tissue,  and  in  part  escape  into  the 
joint  in  the  form  of  pus.  The  soft  tissues  around  the  joint  are 
now  invaded  by  the  granulation-tissue,  abscesses  form,  the  skin 
gives  way,  and  sinuses  are  left  leading  to  the  interior  of  the  joint. 
After  the  inflammatory  products  have  escaped,  should  the  inflam- 
mation subside,  the  layers  of  granulation-tissue,  which  spring  up 
from  the  surface  of  the  bones  that  have  been  denuded  of  their 
cartilage,  come  into  contact,  and  unite  in  the  way  described  under 
union  of  the  soft  parts  by  the  third  intention.  Ossification  sub- 
sequently ensues.  Under  less  favorable  circumstances  the  inflam- 
mation may  assume  a  septic  character,  and  the  abscesses  around 
the  joint  burrow  widely  amongst  the  muscles  and  other  soft  tis- 
sues. Or  the  periosteum  or  the  medulla  of  the  bones  may  be- 
come involved  in  the  septic  inflammation,  and  extensive  caries  or 
necrosis  ensues.  The  septic  products  may  become  absorbed,  and 
the  patient  die  of  saprsemia  or  pyaemia,  or  suppuration  may  con- 
tinue and  death  result  from  hectic  or  lardaceous  disease. 

Signs. — The  disease  may  begin  like  an  ordinary  attack  of 
synovitis,  but  the  pain  soon  becomes  intense  and  agonizing  on 
the  least  movement,  the  heat  more  marked,  and  the  skin  often 
covered  by  a  blush  of  redness.  The  swelling  at  first  takes  the 
form  of  the  synovial  membrane,  but  soon  becomes  general,  and 
the  joint  assumes  a  flexed  position.  In  the  meantime  the  con- 
stitutional disturbance  is  severe,  the  temperature  high,  the  pulse 
rapid,  the  tongue  furred,  and  a  chill  or  rigor  may  perhaps  occur. 
Painful  startings  of  the  joint  now  set  in,  in  consequence  of  the 
reflex  irritation  of  the  muscles ;  abscesses  form  and  make  their 
way  to  the  surface,  and  burrow  in  the  tissues  around  j  and  the 
joint-surfaces  become  displaced  from  each  other  (Fig.  8i). 
After  the  abscesses  have  opened,  the  inflammation  may  subside, 
probably  leaving  the  joint  stiff;  or  the  patient  may  die  of  septic 
poisoning  or  of  exhaustion. 

The    treatment  at    first    should    be    similar    to    that   of  acute 

synovitis  ;  but  should  suppuration  set  in,  the  joint  must  be  freely 

opened  and  antisepticahy  drained,  and   all  abscesses  that   have 

formed   around   treated  in  the   same   manner.     When  effectual 

II 


242  DISEASES    OF    SPECIAL    TISSUES. 

drainage  cannot  be  secured  continuous  irrigation  or  immersion  in 
a  hot  bath  may  be  tried.  If  septic  poisoning  or  exhaustion 
threaten  Ufe,  amputation  must  be  performed. 

Epiphysitis  is  an  inflammation  of  the  soft  growing  tissue  be- 
tween the  shaft  and  the  epiphysis.  It  is  therefore  necessarily 
confined  to  the  young,  and  is  of  most  frequent  occurrence  under 
the  age  of  ten.  It  may  be  acute,  sub-acute,  or  chronic,  and  may 
or  may  not  involve  the  neighboring  joint.  The  epiphyses  most- 
often  affected  are  those  of  the  hip,  knee,  and  shoulder,  but  several 
may  be  imphcated  at  the  same  time,  or  one  after  the  other  in 
rapid  succession. 

Cause. — Slight  injuries,  tubercle,  infective  micro-organisms, 
and  sepsis  as  from  the  absorption  of  a  septic  poison  after  hgature 
of  the  umbilical  cord. 

Pathology. — The  inflammation  as  a  rule  terminates  rapidly  in 
suppuration,  in  which  case  either  the  articular  cartilage  may  be 
perforated  and  the  pus  escape  into  the  joint  setting  up  acute 
arthritis,  or  the  epiphysis  may  become  completely  cut  off  from 
the  diaphysis  and  form,  as  in  the  case  of  epiphysitis  of  the  upper 
end  of  the  femur,  a  loose  sequestrum  in  the  interior  of  the  joint. 
In  less  acute  cases  the  inflammation  may  subside  v/ithout  suppu- 
ration ensuing,  under  which  circumstances  premature  synostosis 
may  take  place  between  the  diaphysis  and  epiphysis,  and  the 
growth  of  the  bone  at  the  affected  end  be  thus  arrested.  The 
chronic  cases  may  also  terminate  in  suppuration  and  destruction 
of  the  joint ;  but  if  this  does  not  occur,  the  prolonged  vascularity 
may  lead  to  increased  nutritive  changes,  and  instead  of  growth 
being  arrested  by  premature  synostosis,  the  bone  may  be  in- 
creased in  length. 

Symptoms. — Severe  constitutional  disturbance  ;  swelling  of  the 
end  of  the  bone  ;  tenderness,  heat,  and  sometimes  redness  of  the 
skin  ;  stiffness  and  fixidity  of  the  joint ;  pain  increased  on  move- 
ment ;  and  jjrobably,  later,  signs  of  acute  arthritis  ;  grating  of  the 
epiphysis  on  the  dia])hysis ;  and  if  the  ca])sule  of  the  joint  bursts, 
the  formation  of  a  large  abscess  in  the  limb.  In  the  chronic 
form  the  signs  are  those  of  the  early  stage  of  tubercular  joint 
disease. 

The  treatment  consists  in  placing  the  limb  in  a  corrected  posi- 
tion on  a  splint,  the  application  of  a  few  leeches,  and  free  in- 
cisions down  to  the  epiphysis  with  antiseptic  precautions  as  soon 
as  there  are  signs  of  suppuration.  Should  it  appear  probable 
that  pus  is  contained  in  the  e])ii)hysis  the  latter  should  be  cau- 
tiously perforated.  If  the  joint,  notwithstanding  this  treatment, 
becomes  affected,  it  must  be  laid  freely  open  and  drained  anti- 
septically,  and  any  secjuestrum  that  may  be  present  removed. 


CHRONIC   TUBERCULAR   ARTHRITIS.  243 

Chronic  tubercular  arthritis,  also  called  tumor  albus  or 
white  swelling,  pulpy  degeneration  of  the  synovial  membrane,  and 
fungous  or  strumous  inflammation,  is  characterized  by  a  gradual 
enlargement  of  the  joint,  unaccompanied  by  redness  or  much  in- 
crease of  synovial  secretion.  It  begins  very  insidiously,  is  chronic 
in  its  course,  and  is  prone  to  end  in  the  total  disorganization  of 
the  joint.  Though  most  frequent  in  the  young,  it  may  occur  at 
any  age. 

Causes. — It  is  generally  attributed  to  some  slight  injury  to  the 
joint,  occurring  in  a  strumous  or  unhealthy  subject ;  but  fre- 
quently no  history  of  any  such  injury  is  forthcoming.  The  im- 
mediate cause  is  the  presence  of  the  tubercle  bacillus  which  has 
gained  admission  to  the  system  in  the  way  described  under 
Tubercle. 

Pathology. — The  disease  may  begin  either  as  a  chronic  inflam- 
mation of  the  synovial  membrane,  or  as  a  fungating  caries  of  the 
articular  ends  of  the  bones;  in  the  former  case,  the  synovial 
membrane,  which  first  appears  red  and  injected,  gradually  be- 
comes thickened  and  oedematous,  and  ultimately  pulpy  and 
gelatinous  and  in  places  fatty  looking.  The  synovial  fluid  in  the 
meantime  becomes  turbid  or  muco-purulent,  but  is  rarely  much 
increased  in  quantity ;  the  synovial  tufts,  at  first  soft  and  floc- 
culent,  gradually  assume  the  form  of  spongy  granulation-tissue, 
and  grow  over  the  cartilage  from  the  sides  till  they  completely 
cover  it,  "  lying  over  it  like  a  veil."  Prolongations  from  this  veil 
of  granulations,  compared  by  Billroth  to  the  roots  of  ivy  pene- 
trating a  wall,  insinuate  themselves  into  and  spread  in  all  direc- 
tions through  the  cartilage,  which  they  ultimately  destroy,  and 
then  in  like  manner  invade  the  bone.  The  granulation-tissue 
may  also  make  its  way  between  the  bone  and  the  cartilage,  and 
unite  with  that  derived  from  the  synovial  membrane,  thus  leaving 
portions  of  cartilage  loose  between  the  two  layers  of  granulations. 
At  the  same  time,  fungous  granulations  derived  from  the  synovial 
membrane  may  invade  the  tissues  around  the  joint,  and  under- 
going caseous  or  fatty  degeneration  in  places,  break  down  into 
abscesses  which  may  open  both  externally  and  into  the  joint, 
leading  to  the  production  of  sinuses  and  fistulge.  The  ligaments 
being  thus  softened  and  destroyed,  allow  the  articular  surfaces  to 
be  dislocated  by  the  contraction  of  the  muscles ;  whilst  the 
muscles  and  bones  themselves,  partly  from  want  of  use  and  partly 
from  the  debilitating  nature  of  the  disease,  undergo  atrophy  and 
fatty  degeneration.  When  the  disease  begins  in  the  bone  it  takes 
the  form  of  a  rarefying  osteitis,  the  fungating  granulations  invade 
the  deeper  surface  of  the  cartilages,  perforate  them,  and  then  set 
up  the  changes  in  the  synovial  membrane  and  other  tissues  d'e- 


244  DISEASES   OP   SPECIAL   TISSUES. 

scribed  above.  The  ininute  changes  which  occur  during  the 
above-mentioned  phenomena  are  those  already  described  under 
inflammation.  All  that  need  be  repeated  here  is,  that  the 
synovial  membrane,  ligaments,  and  in  places  the  surrounding 
tissues,  become  infiltrated  with  small  round  cells,  and  ultimately 
converted  into  a  layer  of  vascular  granulation-tissue  ;  that  the 
cartilage-cells  prohferate  whilst  the  matrix  undergoes  softening 
and  liquefaction  ;  and  that  the  articular  ends  of  the  bones  are 
eroded  and  destroyed  in  the  way  described  under  Caries.  In 
places  in  the  granulation-tissue  are  found  non-vascular  areas,  con- 
sisting of  tubercle  nodules,  in  which  the  tubercle  bacillus  is  found. 
In  the  early  stages  under  appropriate  treatment  the  inflammation 
may  subside,  and  the  joint  resume  its  normal  condition.  After 
the  cartilages,  however,  have  been  destroyed,  such  a  favourable 
ending  is  of  course  impossible,  and  all  that  can  be  hoped  for  is, 
that  the  layers  of  granulations  covering  the  denuded  bones  may 
unite  and  ankylosis  ensue.  The  dangers  to  be  apprehended  are 
that  the  tubercle  should  become  disseminated,  lighting  up 
phthisis,  meningitis,  etc. ;  or  that  long-continued  suppuration 
should  induce  hectic,  exhaustion,  or  lardaceous  disease. 

Signs. — The  disease  is  generally  chronic,  often  lasting  for  years. 
It  usually  begins  very  insidiously  :  there  may  be  some  slight  stiff"- 
ness  of  the  joint,  attributed  perhaps  to  a  trivial  injury,  or  in  the 
case  of  the  lower  extremity  a  slight  limp  in  walking.  The  joint 
may  be  held  in  a  slightly-bent  position,  and  the  range  of  flexion 
and  extension  may  be  somewhat  restricted.  Occasionally  the 
disease  is  ushered  in  by  an  acute  attack  of  synovitis.  At  first 
there  may  be  little  or  no  swelling,  or  the  swelling  may  take  the 
form  of  the  synovial  membrane  ;  but  as  the  disease  advances,  it 
becomes  general  and  uniform,  so  that  the  points  of  bone  about 
the  joint  become  obscured.  The  wasting  and  atrophy  of  the 
tissues  of  the  limb,  however,  give  the  articular  ends  of  the  bone 
the  appearance  of  being  considerably  enlarged.  In  the  meantime 
there  is  no  redness  of  the  skin  ;  hence  the  name  tumor  albus,  or 
white  stvclling.  Pain  at  first  may  be  absent,  or  on!v  present  on 
movements  of  the  limb,  but  gradually  increases  till  the  patient,  in 
the  case  of  the  lower  extremity,  is  prevented  by  it  from  walking. 
There  is  usually  but  little  heat.  In  this  condition  the  joint  may 
remain  for  many  months,  and  under  appropriate  treatment  the 
disease  may  completely  subside.  If  neglected,  however,  the  ar- 
ticular surfaces  of  the  bones,  as  the  ligaments  becomes  softened, 
are  slowly  displaced,  and  painfiil  startings  of  the  limb  at  night  in- 
dicate that  the  bones  are  involved.  Now  tenderness  followed  by 
fluctuation  may  be  detected  at  one  or  more  spots ;  the  skin  be- 
comes red  in  these  situations ;  and  the  abscess  if  not  opened, 


TREATMENl'   OF    CHRONIC    TUBERCULAR    ARTHRITIS.  245 

bursts  externally,  allowing  of  the  escape  of  curdy  pus.  Thus,  by 
the  formation  of  successive  abscesses,  the  tissues  around  the  joint 
are  slowly  undermined,  and  sinuses  and  fistulse  are  formed.  The 
general  health  becomes  more  markedly  affected,  and  although 
even  now  the  sinuses  and  fistulse  may  heal  and  the  patient  ulti- 
mately recover,  though  almost  certainly  with  an  ankylosed  joint, 
suppuration  as  often  continues,  hectic  sets  in,  and  the  patient  dies 
of  exhaustion,  or  succumbs  to  phthisis  or  lardaceous  disease. 

The  treatment  must  be  both  local  and  constitutional.  The 
local  indications  are  (i),  to  place  the  joint  at  absolute  rest  in  a 
position  in  which  it  will  subsequently  be  most  useful  should  anky- 
losis occur;  (2),  to  keep  it  at  rest,  not  only  till  all  signs  of  the 
disease  have  disappeared,  but  for  some  months  afterwards,  to 
prevent  a  relapse  ;  (3),  to  open  and  drain  antiseptically  any  ab- 
scess that  may  form,  or  fully  expose  the  cavity  of  the  joint  and  re- 
move the  diseased  tissues;  and  (4)  in  advanced  and  intractable 
cases  to  save  the  patient's  life  by  the  sacrifice  of  the  limb.  For 
keeping  the  joint  at  rest,  splints  may  be  employed  similar  to  those 
mentioned  under  chronic  synovitis ;  and  in  the  case  of  the  lower 
extremity,  where  there  may  be  flexion  of  the  hip  or  knee,  the 
patient  should  be  placed  in  bed,  and  extension  made  by  a  stirrup, 
weight  and  pulley,  or  by  a  Bryant's  double  splint,  till  the  de- 
formity has  been  overcome.  The  time  the  splints  should  be 
worn  will  vary  in  each  individual  case  according  to  the  progress 
of  the  disease.  Roughly,  it  may  be  said  that  they  will  generally 
be  required  for  many  months,  perhaps  for  several  years,  and  that 
they  must  be  worn  three  months  after  the  disease  has  ceased. 
The  constitittional  means  which  must  be  adopted,  are  those  that 
have  already  been  described  under  the  treatment  of  Tubercle 
(p.  46).  Should  the  disease  progress  in  spite  of  treatment, 
aspiration  and  the  injection  of  iodoform-glycerin  emulsion  may 
be  tried  ;  the  aspirations  and  the  injections  being  repeated  at 
frequent  intervals.  This  failing,  the  joint  may  be  freely  opened, 
the  diseased  synovial  membrane  scraped  or  cut  completely  away 
{arthrectomy),  the  cavity  well  flushed  out  with  an  antiseptic 
solution,  filled  with  iodoform  emulsion,  and  the  wound  closed. 
A  convenient  instrument  for  scraping  out  the  joint  will  be  found 
in  Barker's  flushing  spoon,  which  admits  of  a  stream  of  water  or 
antiseptic  solution  flowing  through  the  joint  whilst  the  scraping  is 
in  progress.  If  the  wound  breaks  down,  the  operation  should  be 
repeated,  or  if  the  whole  of  the  diseased  tissues  cannot  be  re- 
moved an  antiseptic  drain  may  be  employed.  If  the  cartilages 
and  articular  ends  of  the  bone  are  found  much  diseased,  the  joint 
should  be  excised.  Where,  however,  notwithstanding  the  above 
treatment,  abscesses  and  sinuses  continue  to  form,  and  the  patient 


246 


DISEASES    OF   SPECIAL   TISSUES. 


is  becoming  exhausted  by  long-continued  suppuration  and  hectic, 
or  where  signs  of  incipient  phthisis  or  lardaceous  disease  are  be- 
coming manifest,  the  question  of  amputation  must  be  raised. 
Should  recovery  ultimately  occur,  but  with  the  joint  ankylosed  in 
a  faulty  position,  an  osteotomy  or  osteoclasia  may  be  of  service. 
Tubercular  disease  of  the  hip,  though  essentially  similar  to 
tubercular  disease  of  other  joints,  requires  separate  mention,  as 
owing  to  the  depth  and  conformation  of  the  articulation  it  is  at- 
tended with  special  symptoms,  and  calls  for  certain  modifications 
in  the  method  of  treatment. 

Signs. — In  the  early  stages  there  is  slight  lameness,  some  limi- 
tation in  the  range  of  movement  of  the  joint,  generally  pain,  and 
often  quite  early  some  atrophy  and  wasting  of  the  muscles.  The 
pain,  though  at  times  severe,  is  more  frequently  slight,  "^nd  may 
only  be  elicited  on  making  certain  movements  of  the  '^oint.  It 
may  be  felt  in  the  hip,  or  as  is  commonly  the  case,  be  referred  to 
the  knee  or  to  other  parts  supplied  by  the  obturator  nerve,  as  the 
inner  side  of  the  thigh.     At  times  it  may  be  felt  in  both  hip  and 

knee      simultaneously.      The 
^'°-  ^^-  joint  is  slightly  stiff,  not  only 

on  flexion  and  extension,  but 
also  on  rotation  and  on 
abduction  and  adduction, 
especially  in  the  semi-flexed 
position.  There  is  often 
some  fulness  about  the  front 
of  the  joint,  loss  of  the  gluteal 
fold,  and  perhaps  tenderness 
on  pressure.  The  joint  be- 
comes at  first  slightly  flexed, 
everted,  and  abducted,  /.  e., 
it  assumes  the  position  in 
which  the  ligaments  of  the  inflamed  joint  are  most  relaxed — the 
position  of  greatest  ease.  In  order  to  bring  the  flexed  and  ab- 
ducted limb  to  the  ground,  the  pelvis  is  depressed  on  the  affected 
side,  and  hence  the  limb  appears  when  placed  parallel  to  its 
fellow  slightly  lengthened  (P^ig.  82,  a  and  n).  Later,  the  joint 
becomes  further  flexed  ;  but  inverted  instead  of  everted,  and 
adducted  instead  of  abducted,  a  change  of  position  which  has 
been  variously  attributed  to  erosion  of  the  posterior  part  of  the 
acetabulum,  a  yielding  of  the  ligaments,  or  exhaustion  of  the  ex- 
ternal rotator  and  abductor  muscles.  To  overcome  this  position 
of  adduction  in  which  the  limb  is  useless,  the  pelvis  is  raised  on 
the  affected  side,  so  that  the  limb,  if  brought  parallel  to  the  other, 
now  appears  slightly  shortened    (Fig.  82,  c  and  i;)  in  place  of 


To  show  the  effects  of  abduction  (.\',  and  ab- 
duction (CI  in  causing  apparent  lengthening 
(B),  and  apparent  shortening  'V  of  the  limb 
in  hip-joint  disease,  when  the  affected  limb 
is  placed  parallel  to  the  opposite  limb. 


TREATMENT    OF   TUBERCULAR    DISEASE    OF    THE    HIP. 


247 


To  show  the  lordosis  of  the  lumbar  spine  when  the 
limb  is  placed  in  the  straight  position.  P.  Psoas 
muscle. 


being  lengthened.  Whilst  the  position  of  abduction  and  adduc- 
tion is  overcome  by  depressing  or  raising  the  pelvis  respectively 
on  the  affected  side,  /.  e.,  by  laterally  bending  the  lumbar  spine, 
flexion  is  overcome  by  rolling  the  pelvis  forward,  /.  e.,  by  increas- 
ing the  normal  lumbar  curve.  Hence  when  the  patient  is  laid 
on  his  back  and  the  limbs  are  brought  down  parallel  to  each 
other,  there  is  always  considerable  lordosis  of  the  lumbar  spine 
(Fig.  83),  which,  however,  disappears  on  flexing  the  affected 
limb  to  the  angle  at  which 

it   is   held   flexed   by  the  ^'""-^ 

contracted  muscles  (Fig. 
84).  Later  in  the  disease 
real  shortening  ensues, 
owing  to  the  destruction 
of  the  joint  and  the  dislo- 
cation of  the  head  of  the 
bone  on  to  the  dorsum  of  the  ilium.  The  pus  usually  makes  its 
way  towards  the  surface  between  the  tensor  vaginae  and  sartorius, 
and  a  fluctuating  swelling  is 

produced   in  this  situation  a  Fig.  84. 

little  below  and   external   to 
the     joint.       Finally    sinuses 
may    form    and    the   disease 
progress  in  the  way  described 
under     Tubercular    Arthritis. 
Not   infrequently   the    aceta- 
bulum may  become  perforated  and  the  suppuration  extend  into 
the  pelvis.     Pointing  may  then  occur  above  Poupart's  ligament, 
or  the  pus  may  make  its  way  into  the  rectum,  ischio-rectal  fossa 
or  through  the  sciatic  notch. 

Treatineut. — As  regards  constitutional  treatment  nothing  need 
be  added  to  what  was  said  on  pp.  46,  224.  The  indications  for 
the  local  treatment  are  similar  to  those  for  tubercular  disease  of 
the  joints  generally,  but  require  certain  modifications  in  the 
methods  of  carrying  them  out.  Thus  if  the  symptoms  are  acute 
the  patient  should  be  placed  in  bed,  and  extension  made  by  the 
stirrup,  weight  and  pulley  in  the  direction  in  which  the  joint  is 
displaced,  the  limb  being  gradually  brought  down  in  this  way  to 
a  straight  position.  If  the  child  is  restless  a  long  splint  should  be 
placed  on  the  opposite  limb  to  keep  him  from  rolling  to  one  or 
other  side,  whilst  the  foot  of  the  bed  should  be  raised  by  blocks 
to  prevent  him  slipping  down,  or  Bryant's  double  sphnt  may  be 
used  with  great  advantage  in  some  cases  (Fig.  193).  Subse- 
quently, or  at  once  in  subacute  cases,  a  Thomas'  splint  (Fig.  77) 
should  be  applied,  and  after  the  limb  has  been  brought  into  the 


To  show  effect  of  flexing  the  limb  on  the  lumbar 
lordotic  curve.     P.  Psoas  muscle. 


248  DISEASES    OF    SPECIAL    TISSUES. 

Straight  position,  the  patient  may  be  allowed  to  get  about  on 
crutches.  If  in  spite  of  treatment,  the  disease  progresses  and 
pus  forms,  aspiration  and  the  injection  of  iodoform- glycerine 
emulsion  may  first  he  tried,  the  aspiration  and  injection  being 
repeated  at  frequent  intervals.  This  failing,  the  abscess  should 
be  opened,  the  diseased  tissue  scraped  away,  the  cavity  filled 
with  the  iodoform  emulsion  and  the  wound  closed.  The  head 
of  the  bone  if  loose  or  carious  should  be  removed,  as  should  also 
any  carious  bone  that  can  safely  be  got  away  from  the  acetabulum. 
When  all  the  carious  bone  cannot  be  removed,  or  the  suppura- 
tion has  extended  into  the  pelvis,  an  antiseptic  drain  should  be 
employed,  the  wound  being  stuffed  with  iodoform  gauze  daily. 
One  advantage  of  early  incision  is  that  the  pus  in  some  cases 
may  at  first  be  outside  the  joint,  being  dependent  upon  disease 
about  the  great  trochantor,  lower  end  of  the  neck  or  upper  end 
of  the  shaft,  and  so  extension  to  the  joint  may  be  avoided.  In 
intractable  cases  amputation  at  the  hip  joint  is  often  the  only 
chance  of  saving  the  patient's  life.  In  lieu  of  amputation  at  the 
hip,  Mr.  Howse  has  proposed  amputation  through  the  thigh, 
either  as  a  preliminary  to  the  more  serious  amputation  or  alto- 
gether instead  of  it.  He  argues  that  such  a  measure  by  reducing 
the  length  of  lever  having  its  fulcrum  at  the  hip  joint  promotes 
rest,  and  by  removirg  a  mass  of  tissue,  chiefly  blood- consuming, 
and  very  little  blood- producing,  favours  the  production  of  blood 
of  better  quality  and  larger  am.ount ;  whilst  should  amputation  at 
the  hip  become  absolutely  necessary  later  there  would  be  less 
shock  and  the  patient  would  be  better  able  to  bear  it.  Should 
the  patient  recover  but  with  the  limb  ankylosed  in  a  flexed  or 
other  faulty  position,  the  division  of  the  femur  subcutaneously 
with  the  chisel  or  Adams'  saw  below  the  trochanters  will  be  re- 
quired to  put  it  straight. 

Disease  of  the  sacro-ieiac  joint  also  requires  a  separate,  brief 
notice.  It  is  generally  of  tubercular  origin,  but  is  sometimes  ap- 
parently due  to  injury.  It  usually  occurs  in  young  adults,  rarely, 
if  ever,  in  children.  There  is  pain,  swelling,  and  later  redness 
over  the  joint,  followed  by  the  formation  of  abscesses  which  may 
open  posteriorly  or  through  the  sciatic  notch,  above  Poupart's 
ligament,  in  the  ischio-rectal  fossa,  or  in  the  rectum.  The  pain 
may  be  reflected  along  the  sciatic  nerve,  simulating  sciatica,  or 
along  the  obturator  nerve  to  the  hip  or  knee,  and  may  then  be 
increased  on  moving  the  hij).  The  thigh,  moreover,  in  conse- 
quence of  the  irritation  of  the  ])soas,  may  be  slightly  flexed.  The 
disease  may  thus  have  to  be  diagnosed  from  hijj-disease  and 
spinal  caries.  C)n  fixing  the  pelvis,  however,  the  hip  and  spine 
move  freely  and  without  pain,  but  pain  is  felt  on  making  pressure 


DISEASE    OF    THE    SACRO-ILIAC    JOINT.  249 

inwards  or  outwards  on  the  iliac  crests  or  over  the  sacro-iliac 
joint.  When  sinuses  have  formed  carious  bone  may  sometimes 
be  detected  on  probing.  The  prognosis  is  unfavorable.  The 
treatment  consists  in  keeping  the  parts  at  absolute  rest  by  fixing 
the  pelvis  and  thigh  in  a  moulded  leather  sphnt  reaching  to  the 
knee,  and  after  sinuses  have  formed,  in  scraping  and  gouging 
away  as  much  as  possible  the  tuberculous  granulations  and  carious 
bone  and  dressing  with  iodoform. 

Chronic  osteo-arthritis,  also  called  rheumatoid  arthritis,  or 
arthritis  deformans,  is  an  incurable  and  progressive  disease  lead- 
ing to  great  deformity  and  at  times  to  complete  disablement  of 
the  joint.  It  is  characterized  by  gradual  degeneration  and  de- 
struction of  the  cartilages,  eburnation  and  alteration  in  the  shape 
of  the  articular  ends  of  the  bones,  and  formation  of  nodular 
osteophytes  in  the  fibrous  tissue  around  the  joint.  It  is  a  disease 
of  middle  and  advanced  life,  and  may  be  confined  to  one  or  more 
of  the  larger  joints — the  hip,  knee  or  shoulder  {monarthritis),  or 
it  may  affect  many  joints,  including  the  smaller  articulations 
{^polyarticular  rheumatism).  Though  most  frequently  met  with 
in  the  joints  of  the  extremities,  it  may  affect  other  joints,  as  those 
of  the  lower  jaw,  spine,  etc. 

The  catise  is  not  known.  The  disease,  however,  has  been  at- 
tributed to  deficient  or  perverted  innervation,  depressing  nervous 
influences,  exposure  to  cold  and  damp,  improper  feeding,  insuf- 
ficient clothing,  etc.  At  times  a  slight  injury  appears  to  be  the 
determining  cause. 

Pathology. — The  disease  is  variously  believed  to  begin  as  a 
chronic  inflammation  of  the  synovial  membrane,  a  fibroid  degen- 
eration of  the  cartilages,  or  as  an  inflammatory  affection  of  the 
ligaments.  In  whichever  way  it  begins,  however,  the  earliest 
characteristic  changes  are  found  in  the  cartilages.  These  at  first 
appear  nodular  and  cracked,  but  subsequently  become  roughened, 
fibrous  and  villous-looking,  and  are  finally  rubbed  away  by  the 
friction  of  the  articular  surfaces  of  the  joint  on  each  other.  Such 
changes  appear  to  be  due  to  fibroid  degeneration,  or  splitting  of 
the  matrix  into  fibres,  and  the  multiplication,  enlargement,  and 
fatty  degeneration  of  the  cartilage  cells.  Thus  it  will  be  per- 
ceived that  the  process  by  which  the  cartilages  are  destroyed  in 
chronic  osteo-arthritis  differs  materially  from  the  so-called  ulcer- 
ation of  cartilage  which  occurs  in  the  inflammatory  joint-affections 
previously  described,  and  in  which  the  matrix  undergoes  liquefac- 
tion and  softening  consequent  upon  its  invasion  by  the  granula- 
tion-tissue derived  from  the  synovial  membrane  and  bone.  In 
chronic  osteo-arthritis  the  synovial  membrane,  at  first  dry,  be- 
comes slightly  thickened  and  vascular,  and  moderately  distended 


250 


DISEASES   OF   SPECIAL   TISSUES. 


with  turbid  synovial  fluid  which  at  times  resembles  train  oil.  In 
the  meanwhile  the  synovial  fringes  become  hvpertrophied,  and 
assume  the  form  of  pedunculated  processes,  often  containing  little 
masses  of  cartilage  or  bone.  These  little  masses  may  subsequently 
become  detached  and  form  loose  bodies 
^■'^•85.  in  the  joint   (Fig.  85).     The  articular 

surfaces  of  the  bone  become  smooth, 
hard,  polished,  eburnated  or  porcellan- 
eous in  appearance  and  variously  altered 
in  shape — changes  apparently  depend- 
ing in  part  on  friction  and  mechanical 
pressure,  and  in  part  on  the  formation 
of  new  bone  in  the  cancellous  spaces, 
whereby  the  bone  is  rendered  harder 
and  is  capable  in  consequence  of 
receiving  a  higher  polish.  Whilst,  how- 
ever, new  bone  is  being  formed  immedi- 
ately beneath  the  polished  surface,  rare- 
faction and  atrophy  are  going  on  a  little 
deeper  in  the  bone  leading  to  the  short- 
ening and  distortion  so  commonly  ob- 
served. Hence,  for  example,  the  flat- 
tening and  enlargement  of  the  aceta- 
bulum and  glenoid  cavity,  and  the 
absorption  of  the  neck  and  flattening  of  the  head  of  the  femur 
and  humerus,  seen  in  osteo-arthritis  of  the  hip  (Fig.  86)  and 
shoulder  respectively.  At  times  the  new  bone  in  the  can- 
cellous spaces  and  Haversian  canals  is  not  formed  as  quickly  as 
the  polished  layer  of  bone  is  worn  away,  and  the  open  ends  of 
the  enlarged  Haversian  canals  give  the  articular  surf^ice  a  worm- 
eaten  appearance.  In  the  meantime  out-growths  of  cartilage 
take  place  around  the  articular  surfaces  and  undergo  ossification, 
forming  the  low  nodular  flattened  osteophytes  and  the  "lipping" 
of  the  articular  ends  of  the  bone  so  characteristic  of  the  disease. 
Ossification  may  also  occur  in  the  ligaments,  tendons,  and  other 
soft  structures  around. 

S(ii>/s. — When  the  disease  is  fully  established  it  may  be  known 
by  pain,  increased  on  movement,  and  often  worse  at  night  and 
during  changes  of  the  weather;  a  characteristic -creaking  and 
harsh  grating  felt  on  moving  the  joint ;  the  detection  of  masses  of 
bone  around  ;  the  limitation  of  the  movement  of  the  joint ;  and 
absence  of  heat  and  redness.  In  the  hip  there  may  be  eversion, 
shortening  and  much  lameness  ;  in  the  knee,  swelling  and  thick- 
ening of  the  synovial  membrane,  and  deformity  of  the  patella  ; 
and  in  the  shoulder,  enlargement  or  displacement  of  the  head  of 


Chronic  osteo-arthritis  of  the 
knee-joint.  The  articular  sur- 
face of  the  tibia  is  shown  in 
the  upper  part  of  the  figure: 
the  patella  is  turned  down. 
I  St.  Bartholomew's  Hospital 
Museum.) 


Charcot's  disease.  251 

the  bone.  In  the  hip  the  disease  may  closely  simulate  intracap- 
sular fracture  of  the  neck  of  the  femur ;  in  the  shoulder,  disloca- 
tion of  the  humerus.  (See  Fracture  of  Femur  and  Dislocation 
of  Shoulder.^ 

Treatment. — Although  the  disease  cannot  be  cured,  and  may 


-4.". 


Chronic  osteo-arthritis  of  the  hip.     (St.  Bartholomew's  Hospital  ^luseum.) 

get  steadily  worse  as  the  patient  grows  older,  much  can  be  done 
in  the  way  of  relief.  Thus  the  whole  body  should  be  warmly 
clad,  the  diet  carefully  regulated,  stimulants  prohibited  or  re- 
stricted in  quantity,  and  a  periodical  visit  paid  to  such  spas  as 
Buxton,  Harrogate,  Bath,  Wiesbaden,  Aix-les-Bains,  or  Wildbad. 
Locally,  massage,  friction,  and  passive  movements,  should  be 
from  time  to  time  employed ;  the  joint  should  be  enveloped  in 
wool  or  flannel,  but  should  not  be  kept  at  rest  on  a  splint,  since 
this  will  only  tend  to  increase  the  stiffness.  In  the  way  of  drugs, 
cod-liver  oil,  iodine,  iodide  of  potassium,  arsenic,  and  guaiacum, 
are  of  most  service.  Blisters  and  fumigations  of  sulphur  are 
recommended  for  reheving  the  pain. 

Charcot's  disease  is  an  affection  of  the  joints  closely  resem- 
bling osteo-arthritis.  It  is  believed  by  some  to  depend  upon 
degenerations  in  the  spinal  cord  (locomotor  ataxia)  and  there- 
fore to  be  the  result  of  trophic  changes  in  the  joints.  Others, 
however,  regard  it  merely  as  an  osteo-arthritis  occurring  accident- 
ally in  a  patient  the  subject  of  locomotor  ataxia.     The  patholog. 


252  DISEASES   OF   SPECIAL   TISSUES. 

ical  changes  are  similar  to  those  already  described  under  osteo- 
arthritis, but  the  destruction  of  the  joint  is  more  marked.  Briefly 
they  may  be  said  to  consist  in  erosion  of  the  cartilages,  softening 
of  the  ligaments,  grinding  away  of  the  articular  surfaces  and  often 
of  the  contiguous  portions  of  the  shaft  of  the  bone,  induration  of 
the  remaining  portions  of  the  articular  surfaces,  thickening  and  at 
times  pouchings  of  the  synovial  membrane,  and  formation  of 
osteophytes  around.  Suppuration  is  very  rare.  These  changes 
may  affect  one  joint  only,  or  may  occur  successively  in  several 
joints. 

The  signs  in  a  typical  case  are  as  follows  : — Sudden  swelHng  of 
a  joint,  usually  without  much  pain  or  any  marked  signs  of  inflam- 
mation, followed,  on  the  subsidence  of  the  sweUing,  by  preter- 
natural mobility,  and  the  formation  of  processes  of  bone  about 
the  articular  surfaces  and  in  the  surrounding  muscles  and  tendons. 
There  is  great  deformity,  but  not  much  pain  either  on  movement 
or  handling.  Along  with  the  local  signs  there  are  generally 
symptoms  of  locomotor  ataxia,  such  as  an  unsteady  gait,  a  ten- 
dency to  fall  on  placing  the  feet  together  with  the  eyes  closed,  a 
jerking  movement  of  the  limbs,  absence  of  the  patella-tendon- 
reflex,  lightning  pains,  spasmodic  muscular  contractions,  local 
anaesthesia  and  sweating  of  the  limbs,  loss  of  response  of  the 
pupil  to  light,  but  no  loss  of  the  power  of  accommodation  ( Argyll- 
Robertso7i  pupil) ,  sometimes  optic  neuritis,  bladder  troubles,  and 
loss  of  sexual  power.  The  joints  most  often  affected  are  the 
knee,  hip,  and  shoulder.  In  the  tarsus  the  bones  on  the  sub- 
sidence of  the  swelling  of  the  synovial  membrane,  though  at  first 
felt  to  be  loosened  by  the  softening  of  the  ligaments,  may  ulti- 
mately become  ankylosed.  Tieatmcfii. — Beyond  keeping  the 
part  at  rest  during  an  acute  attack,  and  adopting  the  same  gen- 
eral treatment  as  is  appropriate  for  osteo-arthritis  and  locomotor 
ataxia,  little  can  be  done.  To  relieve  the  pain  antipyrin  and 
antifebrin  may  be  tried.     Suspension  has  at  times  been  of  service. 

Loose  Bodies  in  a  joint  may  be  formed  in  several  ways,  of 
which  the  following  are  the  chief: — i,  by  the  jiroliferation  of  the 
cartilage  cells  that  normally  exist  in  the  synovial  fringes,  and  the 
subsequent  detachment  of  the  little  mass  of  cartilage  so  formed 
through  the  rupture  of  its  peduncle  in  the  movements  of  the 
joint  (Fig.  87)  ;  2,  by  thickening  or  hypertrophy  of  a  synovial 
fringe,  or  by  extravasation  and  subsequent  organization  of  blood 
in  a  synovial  fringe,  detachment  occurring  in  a  manner  similar  to 
that  in  the  former  case  ;  3,  by  necrosis  of  a  portion  of  the 
articular  cartilages ;  and  4,  by  chipping  off  of  a  portion  of  the 
articular  cartilage  during  some  injury  to  the  joint.  Loose  car- 
tilages are   most  common  in  the  knee,  but  may  be  met  with  in 


LOOSE    BODIES. 


253 


Fig.  87. 


any  joint.  They  are  generally  single,  but  may  be  multiple,  and 
vary  in  size  from  a  pea  to  a  walnut. 

Symptoms. — The  chief  symptom  is  pain,  due  to  the  loose  body 
slipping  between  the  ligaments  and  articular  surfaces  during  the 
movements  of  the  joint.  In  the  knee  this  occurs  during  flexion ; 
and  on  the  patient  attempting  to  straighten  the  joint  the  loose 
body,  by  forcing  the  articular  surfaces  apart,  stretches  the  liga- 
ments, and  thus  gives  rise  to  a  sudden  and  excruciating  pain, 
perhaps  so  severe  as  to  cause  him  to  fall.  At  times  the  loose 
body  remains  fixed  between  the  articular  surfaces,  the  patient 
being  then  unable  to  straighten  his  limb. 
Such  an  attack  may  be  followed  by 
synovitis.  On  examination  the  body 
may  often  be  felt  somewhere  in  the 
synovial  pouch,  probably  on  the  outer 
side  of  the  joint  in  the  case  of  the  knee. 
If  attached,  its  movements  will  be  lim- 
ited, but  if  free  it  can  frequently  be  made 
to  move  round  to  the  opposite  side  of 
the  joint.  It  may  perhaps  disappear  by 
passing  into  some  of  the  synovial  re- 
cesses, though  it  can  generally  be  felt 
again  on  moving  the  joint. 

lyeatnient. — If  the  loose  body  gives 
rise  to  little  or  no  trouble,  and  can  be 
easily  fixed  by  a  pad  and  bandage  or 
knee-cap,  it  should  not  be  interfered 
with ;  nor  should  any  operation  be  un- 
dertaken where  the  joint  is  disorganized 
by  osteo-arthritis,  or  where  the  synovial 
membrane  is  studded  with  masses  of  car- 
tilage.    Under  other  circumstances  the 

loose  body  should  be  removed.  This  may  be  done  either  by  the 
direct  or  the  indirect  method.  The  former  consists  in  transfixing 
the  loose  cartilage  by  a  strong  needle  on  a  handle  thrust  through 
the  skin,  so  that  the  loose  body  may  not  slip  away  or  be  lost  dur- 
ing the  operation,  and  then  cutting  down  on  the  capsule,  and 
when  all  bleeding  has  been  stopped,  opening  the  joint.  The 
body  if  loose  will  generally  slip  through  the  opening  ;  if  attached, 
its  pedicle  must  be  ligatured  and  divided.  The  operation  should 
be  performed  with  the  strictest  antiseptic  precautions,  and  the 
patient  prepared  by  a  week's  rest  in  bed,  in  the  case  of  the  knee 
with  his  joint  on  a  splint.  The  splint  should  be  continued  after 
the  operation,  or  the  joint  placed  in  a  plaster-of- Paris  bandage 
till  the  wound  has  healed  and  all  fear  of  inflammation  has  passed.- 


The  formation  of  a  loose  car- 
tilage in  a  joint.  A  little  mass 
of  cartilage  attached  by  a 
slender  stalk.  (St.  Bartholo- 
mew's Hospital  Museum.) 


254 


DISEASES    OF   SPECIAL   TISSUES. 


The  indirect  method  consists  in  incising  the  capsule  subcutane- 
ously  with  a  tenotomy  knife,  forcing  the  loose  body  through  the 
incision  into  the  connective  tissue  around  the  joint,  and  then 
either  allowing  it  to  lemain  there  permanently,  or  removing  it 
after  the  hole  in  the  capsule  has  healed.  The  operation  is  diffi- 
cult to  perform,  and  since  the  introduction  of  antiseptics  pos- 
sesses no  advantage  over  the  direct  method. 

Ankylosis  or  stiff  joint  may  be  divided  into  the  fibrous  and 
the  bo7iy.  A  spurious  form  of  ankylosis,  due  to  the  contraction 
of  the  surrounding  muscles  or  of  cicatrices  after  burns,  may  also 
occur,  but  is  generally  associated  with  some  amount  of  fibrous 
ankylosis. 

Fibrous  ankylosis,  also  called  ligamentous,  or  by  some  authors, 
false,  in  contradistinction  to  the  bony 
which  they  then  term  true,  is  the 
union  more  or  less  complete  of  the 
articular  surfaces  of  the  joint  by 
fibrous  tissue.  Thus,  it  may  consist 
of — I,  a  mere  thickening  of  the  cap- 
sule ;  2,  a  thickening  and  shortening 
of  the  ligaments  ;  3,  the  formation 
of  fibrous  bands  within  the  joint ;  4, 
the  partial  removal  of  the  cartilages 
and  the  union  of  the  bones  by  fibrous 
tissue;  and  5,  the  above  conditions 
variously  combined.  It  may  be  the 
result  of  joint-disease,  or  of  keeping 
an  inflamed  joint  too  long  in  a  state 
of  rest.  Sometimes  it  may  terminate 
in  bony  ankylosis. 

Bony  ankylosis  is  the  firm  union  of 
joint  by  bone.  It  is  often  a  further 
'J'he  articular  surfaces  may  be  united 
evenly  and  uniformly,  or  by  irregular  bridges  of  bone,  or  partly 
by  bone  and  partly  by  fibrous  tissue.  The  union  may  occur  with 
the  articular  surfaces  in  contact  in  either  the  extended  or  the 
flexed  position,  or  at  an  angle  between  the  two  (Fig.  88)  ;  or  it 
may  occur  with  the  articular  surfaces  dislocated  from  each  other. 
The  way  in  which  it  is  produced  has  already  been  described 
under  Arthritis  :  all  that  need  be  repeated  here  is,  that  in  tuber- 
culosis disease,  ankylosis  and  caries  may  often  be  observed  at  the 
same  time. 

The  sii^ns  of  ankylosis  are  obvious — /.  <?.,  the  joint  is  stiff.  It 
only  remains  to  diagnose  the  fibrous  from  the  bony.  In  the 
former  there  is  slight  movement,  and  generally  pain ;  in  the  latter 


Bony  ankylosis   of   the    hip.      (St. 
Bartholomew's  Hospital  Museum.) 

the  articular  ends  of  the 
stage  of  the  fibrous  variety. 


NEURALGIA   OF   JOINTS.  255 

neither  movement  nor  pain.  In  some  instances,  however,  as  in 
ankylosis  of  the  shoulder  and  hip,  it  may  be  necessary  to  place 
the  patient  under  an  anaesthetic,  as  the  joint  may  be  held  so 
firmly  by  the  contraction  of  the  muscles  that  the  fibrous  may 
simulate  the  bony  form,  and  again,  although  bony  ankylosis  may 
exist,  the  revolving  of  the  scapula  or  pelvis,  as  the  case  may  be, 
on  the  trunk  may  make  it  appear  that  there  is  some  movement  in 
the  affected  joint. 

The  ticaiment  will  vary  with  the  nature  of  the  ankylosis.  In 
the  spurious  form  something  may  often  be  done  by  dividing  the 
cicatrices,  or  by  freeing  the  parts  by  a  plastic  operation,  though  in 
such  cases  the  treatment  is  seldom  very  hopeful.  /;/  the  fibrous 
form  an  attempt  should  be  made  to  restore  the  natural  move- 
ments of  the  joints — i,  by  manipulation,  friction,  and  passive 
movements  ;  2,  by  forcibly  breaking  down  the  adhesions  under 
an  anaesthetic,  at  the  same  time  dividing  any  tendons  that  may 
offer  resistance;  or  3,  by  gradual  extension  by  a  weight  and 
pulley,  or  some  form  of  cog-wheel  or  screw  apparatus.  An  at- 
tempt to  break  down  adhesions,  however,  should  on  no  account 
be  made  whilst  any  signs  of  inflammation  remain,  and  after  the 
operation  the  hmb  should  be  placed  on  a  splint  for  a  few  days, 
and  cold  by  means  of  I.eiter's  tubes  or  an  ice-bag  applied  to  pre- 
vent inflammation.  Bony  ankylosis,  with  the  limb  in  a  good 
position,  is  often  the  best  result  that  can  be  hoped  for  after  the 
disease  of  the  joint  has  reached  a  certain  stage.  But  in  some 
instances  an  operation  may  be  required  to  restore  movement,  or 
to  rectify  a  faulty  position.  Thus  in  an  ankylosed  elbow, 
especially  when  fixed  in  the  extended  position,  excision  of  the 
joint  should  be  practised.  In  a  bent  knee  a  wedge-shaped  piece 
may  be  removed,  or  an  osteotomy  done.  In  the  hip,  subcutane- 
ous osteotomy  of  the  neck  of  the  femur  or  of  the  shaft  just  below 
the  trochanters  may  be  undertaken.  In  the  shoulder,  no  opera- 
tion as  a  rule  is  required,  as  the  movement  of  the  scapula  on  the 
trunk  is  very  free.  When  ankylosis  is  accompanied  by  much 
wasting  of  the  limb,  amputation  may  be  necessary. 

Neuralgia  of  joints. — Pain  of  a  neuralgic  character  un- 
associated  with  heat,  redness,  swelling,  or  physical  signs  of  organic 
disease,  is  occasionally  met  with  in  one  or  more  joints,  especially 
in  young  women  of  the  neuro-mimetic  temperament.  They  are 
very  difficult  cases  to  deal  with,  and  should  receive  the  greatest 
care  and  attention,  lest  an  erroneous  diagnosis  be  made.  Nearly 
all  the  signs  of  organic  joint-disease  may  be  simulated;  thus, 
there  may  be  pain  on  movement,  or  some  slight  redness  and  heat 
of  the  part,  or  fixity  of  the  joint.  The  pain,  however,  is  generally 
superficial,  and  is  not  increased  on  movement  of  the  joint  if  the 


256  niSEASES    OF   SPECIAL   TISSUES. 

patient's  attention  in  the  meanwhile  is  otherwise  engaged  ;  the 
redness  and  heat  will  often  be  found  on  inquir}'  to  be  due  to  pre- 
vious friction  or  the  use  of  irritants  ;  and  under  an  anccsthetic 
the  rigidity  of  the  joint  completely  disappears,  its  movements 
then  being  found  to  be  free,  smooth,  and  natural.  Further,  on 
recovery  from  the  anesthetic,  the  rigidity  does  not  return  until 
the  patient  again  directs  her  attention  to  the  joint,  whereas  in 
organic  disease  it  returns  as  soon  as  the  muscular  relaxation 
ceases.  The  treatment  consists  in  the  employment  of  the  ordi- 
nary remedias  for  neuralgia,  both  locally  and  internally.  Where 
the  patient  is  of  a  neuro  mimetic  temperament,  and  organic  dis- 
ease is  simulated,  approjuiate  hysterical  treatment  must  be 
adopted.     See  a  work  on  Medicine. 

Arthrectomy  or  erasion  of  joints  consists  in  scraping  or  cut- 
ting away  the  whole  of  the  diseased  synovial  membrane,  after  the 
cavity  of  the  joint  has  been  fully  exposed  by  some  such  incision 
as  that  employed  in  excisions.  It  is  a  useful  addition  to  our 
methods  of  treating  diseased  joints,  and  appears  to  be  especially 
indicated  for  those  cases  in  which  the  disease  is  too  far  advanced 
to  yield  to  the  ordinary  plan  of  treatment,  but  has  not  as  yet,  or 
at  least  only  to  a  slight  extent,  involved  the  cartilages  and  bones. 

Excision  or  resection  of  joints  consists  in  cutting  away  the 
articular  surfaces  of  the  bones  entering  into  the  affected  joint,  or 
in  removing  a  portion  of  bone  where  osseous  ankylosis  has  taken 
place.  When  excision  is  done  for  disease  it  may  be  said  here  to 
prevent  repetition  that  the  whole  of  the  diseased  synovial  mem- 
brane should  be  cut  or  scraped  away,  as  should  also  the  lining 
membrane  of  any  sinuses  that  may  be  present.  Excision  may  be 
required  for  severe  injury  or  for  intractable  disease  of  the  joint. 
Space  does  not  permit  of  the  discussion  of  the  various  conditions 
under  which  excision  should  or  should  not  be  performed,  but  it 
may  briefly  be  stated  that  it  should  not  be  undertaken — i,  when 
the  disease  is  acute  ;  2,  when  there  is  much  destruction  of  the 
bones,  or  riddling  of  the  soft  parts  with  sinuses  \  3,  when  there  is 
much  atrophy  of  the  bones  and  muscles ;  4,  when  the  patient  is 
under  the  age  of  ten  or  over  that  of  forty,  as,  in  the  former  in- 
stance, the  epiphyses  are  liable  to  be  removed  and  the  growth 
arrested  in  conseciuence,  and  in  the  latter,  the  powers  of  repair 
are  usually  insufficient  to  ensure  sound  healing  and  a  subsequently 
useful  limb;  5,  when  there  is  lardaceous  disease  or  signs  of 
phthisis,  or  other  organic  mischief;  and  6,  when  the  patient's 
condition  is  such  that  the  excision  would  probably  be  attended 
with  long-continued  suiipuration  and  conseciuent  exhaustion  or 
lardaceous  disease.  Under  most  of  the  above  circumstances 
amputation  is  generally  indicated.     Excision  is  usually  attended 


THE    ELBOW.  257 

with  the  best  success  in  the  elbow,  and  here  it  may  be  done  at  a 
later  period  of  life  than  that  assigned  above  as  the  Hmit.  In  the 
shoulder,  elbow,  and  wrist,  fibrous  ankylosis  is  aimed  at  in  order 
to  secure  a  movable  joint ;  in  the  hip  and  knee,  firm  bony  union 
is  sought  in  the  most  useful  position  of  the  limb,  which  is  that  of 
extension. 

Excision  of  special  joints. — The  shoulder. — Excision  of  the 
shoulder  is  generally  practised  for  gunshot  injuries  and  for  inno- 
cent tumois  in  the  head  of  the  bone.  It  is  seldom  pei formed  for 
disease  of  the  joint,  as  an  equally  useful  joint  may  be  obtained  by 
osseous  ankylosis.  It  should  never  be  done  for  osseous  ankylosis, 
as  the  movements  of  the  scapula  on  the  tiunk  are  so  free,  that 
they  compensate  to  a  great  extent  for  the  fixed  condition  of  the 
joint,  and  little  would  be  gained  by  the  operation.  Of  late  ex- 
cision has  been  employed  for  unreduced  dislocations  of  the 
shoulder,  where  after  free  exposure  and  division  of  contracted 
tendons  and  ligaments,  the  bone  cannot  be  replaced.  The  opera- 
tion.— Make  an  incision  about  four  inches  long  from  just  outside 
the  coracoid  process  through  the  substance  of  the  deltoid  down 
to  the  bone  ;  detach  the  long  tendon  of  the  biceps  from  its  groove, 
and  give  it  to  an  assistant  to  hold  aside  with  blunt  hooks.  The 
arm  being  rotated  inwards,  divide  the  teres  minor,  infraspinatus 
and  supraspinatus  tendons  at  their  insertion  into  the  bone.  The 
arm  being  next  rotated  outwards,  divide  the  tendon  of  the  sub- 
scapularis,  and  the  head  of  the  bone  can  be  pushed  out  of  the 
incision.  Separate  the  periosteum  as  far  as  is  necessary,  place  a 
retractor  behind  the  neck  of  the  bone  to  protect  the  soft  parts, 
and  saw  it  across.  Bring  the  wound  together  by  sr.ture,  place  a 
drain  tube  in  the  lower  part,  and  dress  antiseptically. 

The  elbow  may  be  excised  for  chronic  disease  of  the  joint, 
gunshot  or  other  injury,  and  osseous  ankylosis.  Some  surgeons 
only  recommend  excision  for  ankylosis  when  the  elbow  is  fixed 
in  a  faulty  position.  The  operation,  however,  is  attended  with  so 
little  risk,  the  advantages  of  a  movable  elbow  are  so  great,  and 
the  results  so  good,  that  others  unhesitatingly  excise  the  joint  in 
whatever  position  ii  may  be  fixed.  The  operaiion  may  be  per- 
formed in  several  ways ;  but  that  by  the  single  vertical  incision 
{Lafigenbeck's)  is  undoubtedly  the  best  and  the  one  most  fre- 
quently practised.  Make  a  vertical  incision  about  five  inches 
long  over  the  back  of  the  joint,  beginning  about  two  and  a  half 
inches  above  the  olecranon,  and  carry  it  over  this  process  and 
down  the  ridge  on  the  ulna  for  the  same  distance.  The  incision 
should  extend  in  its  whole  length  down  to  the  bones.  Cut  into 
the  joint  above  the  olecranon  and  clear  the  condyles  of  the  soft 
tissues  by  keeping  the  edge  of  the  knife  in  contact  with  the  bone. 
II* 


258  DISEASES    OF    SPECIAL    TISSUES. 

taking  special  care  not  to  injure  the  ulnar  nerve  behind  the 
internal  condyle.  Divide  the  lateral  ligaments,  and  whilst  the 
assistant  strongly  flexes  the  joint  to  force  the  bones  out  of  the 
wound,  free  them  from  their  remaining  connections,  and  saw  off 
the  olecranon,  the  head  of  the  radius,  and  the  lower  end  of  the 
humerus,  steadying  the  parts  with  the  lion  forceps.  If  possible, 
the  coronoid  process  of  the  ulna  and  the  tubercle  of  the  radius 
should  not  be  removed,  and  the  shaft  of  the  humerus  not  en- 
croached upon.  Preserve  the  connection  of  the  anconeus  with 
the  triceps,  as  better  extension  of  the  arm  will  be  thus  obtained. 
Unite  the  wound  by  sutures,  after  inserting  a  drain,  and  place  the 
limb  on  a  splint  in  the  flexed  position.  Callender's  splint  is  one 
of  the  best  for  the  purpose,  as  it  permits  of  passive  motion  not 
only  in  the  direction  of  flexion  and  extension,  but  also  in  that  of 
pronation  and  supination,  and  without  removing  the  arm  from  the 
splint.  It  also  allows  of  the  limb  being  slung  by  pulleys  from  the 
ceiling,  which  is  much  more  comfortable  for  the  patient  than 
placing  it  on  a  pillow.  Passive  movements  should  be  begun  at 
the  end  of  the  first  or  second  week,  the  aim  of  the  surgeon  being 
to  obtain  a  m.ovable  joint. 

The  WRIST  may  be  excised  for  chronic  disease  of  the  wrist  and 
carpal  joints.  The  operation  is  very  successful  in  suitable  cases  ; 
these,  however,  are  rarely  met  with,  as,  if  the  disease  is  extensive, 
it  is  as  a  rule  better  to  amputate,  and  if  limited,  gouging  away  the 
diseased  bone  will  generally  suffice.  The  operaiiou  usually  done 
is  that  now  known  as  Lister's.  It  consists  in  removing  all  the 
bones  of  the  carpus,  the  bases  of  the  metacarpal  bones,  and  the 
lower  end  of  the  radius  and  ulna,  the  incisions  being  so  planned 
as  to  avoid  cutting  the  numerous  tendons  surrounding  the  joint 
and  the  radial  artery.  As  the  operation  is  rarely  performed, 
further  details  will  not  be  given. 

The  hip  may  be  excised — (1)  when  the  head  of  the  bone  has 
become  necrosed,  and  lies  loose  in  the  joint ;  (2)  when  suppura- 
tion continues  in  spite  of  free  drainage  and  antiseptics  ;  (3)  when 
in  addition  to  suppuration  the  head  of  the  bone  is  dislocated,  and 
the  limb  cannot  be  placed  in  a  useful  position.  Excision  should 
not  be  done  when  there  is  extensive  disease  of  the  pelvis  or  femur, 
or  signs  of  lardaceous  disease  or  of  phthisis.  Under  these  cir- 
cumstances amputation  is  the  only  resource.  For  ankylosis  in  a 
faulty  position  subcutaneous  osteotomy  of  the  neck  of  the  femur 
or  of  the  shaft  of  the  bone  below  the  trochanters  is  preferable  to 
excision.  The  operation. —  i.  By  the  rt!;//<?;7V;r  incision.  Make  an 
incision  four  inches  long  from  half  an  inch  below  the  anterior 
superior  iliac  spine  downwards  and  a  little  inwards  between  the 
sartorius  and  rectus  on  the  inner  side  and  the  tensor  vagina;  and 


THE    KNEE,  259 

glutei  on  the  outer  side,  and  open  the  joint  from  the  front.  2.  By 
the  posterior  incision.  Make  a  slightly  curved  incision  about  four 
inches  long  behind  the  great  trochanter,  and  after  dividing  the 
glutei,  open  the  capsule  from  behind.  Whichever  incision  is 
made,  insert  the  finger  into  the  joint,  and  with  this  as  a  guide  saw 
through  the  neck  of  the  femur  with  Adams's  saw,  or  Gowan's 
osteotome,  and  remove  the  head  thus  detached  with  sequestrum 
forceps.  The  great  trochanter  should  be  spared  if  possible.  It 
is  important  to  avoid  protruding  the  end  of  the  bone  out  of  the 
wound,  since  the  periosteum  may  in  this  way  be  stripped  up,  and 
thus  lead  to  further  necrosis.  Examine  the  acetabulum,  and  re- 
move any  carious  bone  or  sequestrum  that  may  be  discovered 
with  the  gouge  or  sequestrum  forceps.  Place  the  limb  in  the 
position  of  abduction  on  a  double  Thomas's  splint,  so  as  to  bring 
the  stump  of  the  neck  into  the  acetabulum,  and  thus  leave  as  little 
space  as  possible  between  the  bones.  After  ankylosis  has  taken 
place  the  abducted  position  is  of  advantage,  in  that  to  bring  the 
limbs  parallel  in  walking  the  pelvis  will  have  to  be  depressed  on 
the  affected  side,  and  thus  a  good  inch  of  lengthening  is  obtained 
to  compensate  for  the  shortening  produced  by  the  excision  of  the 
head  of  the  bone.  Some  surgeons  now  no  longer  use  a  drain-tube, 
but  bring  the  deeper  parts  of  the  wound  together  by  buried  sutures, 
and  having  lightly  closed  the  skin  incision  apply  firm  pressure  over 
a  dry  antiseptic  dressing,  so  as  to  keep  the  tissues  in  close  appo- 
sition and  thus  obtain  union  by  the  first  intention. 

The  knee. — Provided  none  of  the  contra-indications  to  excision 
already  enumerated  are  present,  the  knee  may  be  excised  for  in- 
tractable disease  of  the  synovial  membrane,  especially  where  the 
articular  surfaces  are  much  displaced,  or  for  ankylosis  in  a  faulty 
position.  In  the  latter  instance,  however,  a  subcutaneous  osteo- 
tomy is  often  preferable.  The  operation. — The  knee  being  held 
in  a  flexed  position  by  an  assistant,  make  an  incision  from  the 
posterior  part  of  the  condyle  on  one  side,  across  the  front  of  the 
joint  midway  between  the  patella  and  the  tubercle  of  the  tibia, 
to  the  corresponding  situation  on  the  other.  Raise  the  flap  of 
skin  with  the  subcutaneous  tissue  thus  mapped  out,  and  open  the 
joint  by  cuttmg  into  it  above  the  patella,  or  the  patella  may  be 
sawn  across  and  the  fragments  wired  at  the  end  of  the  operation. 
Divide  the  lateral  and  crucial  ligaments,  and  saw  off  a  thin  slice 
of  bone  from  the  lower  end  of  the  femur  and  from  the  upper  end 
of  the  tibia,  taking  care  not  to  injure  the  popliteal  artery,  which 
lies  close  to  the  back  of  the  joint,  and  is  only  separated  from  it 
by  the  posterior  ligament.  If  possible,  the  whole  of  the  epiphysis 
should  not  be  removed.  The  wound  should  then  be  closed  with 
sutures,  a  small  drain  being  inserted  on  each  side.     Mr.  Morrant 


26o 


DISEASES   OF   SPECIAL   TISSUES. 


Fig. 


Baker  secures  the  articular  surfaces  in  contact  by  means  of  steel 
needles  fitted  with  handles.  The  needles  are  passed  through  the 
skin  and  obliquely  through  the  bones  on  each  side  of  the  joint,  the 
handles  removed,  and  the  ntedles  left  /;/  situ  till  union  has  oc- 
curred. Others  substitute  bone  pegs  for  the  needles,  passing  the 
pegs  along  the  holes  made  by  the  needles. 
The  pegs  are  then  cut  off  short  and  left 
in  permanently.  Tenotomy  of  the  ham- 
string tendons  may  be  required  to  bring 
the  bones  into  apposition  if  there  has 
been  much  displacement.  The  limb 
should  then  be  placed  in  plaster-of-Paris 
or  on  a  Gant's  or  other  form  of  excision- 
splint  ;  but  the  kind  of  splint  is  not  very 
material  if  the  bones  are  well  secured  in 
good  position  by  the  pegs  in  the  way 
described  above.  After  convalescence 
the  knee  should  be  kept  for  at  least  a 
year  in  a  well-fitting  leather  splint,  as 
there  is  a  great  tendency  for  the  bone 
to  yield  and  the  limb  to  become  flexed. 
In  ankylosis  in  the  semi-flexed  position, 
in  place  of  removing  a  wedge  of  bone  a 
curved  incision  may  be  inade  through 
the  bone  with  Butcher's  saw,  and  the 
tibia  thus  slid  round  the  femur  into  the  straight  ]josition  (Fig. 
89).  By  this  method  no  bone  is  removed,  and  the  epiphyses 
being  spared  there  is  less  danger  of  a  shortened  limb.  I  have 
obtained  excellent  results  from  it  in  two  cases. 

The  ANKLE. — Excision  of  the  ankle  is  too  rarely  required  in 
practice  to  call  for  a  description.  The  results  following  it,  more- 
over, are  so  unsatisfactory,  that  in  disease  of  the  ankle-joint  either 
Syme's  operation,  or  amputation  through  the  lower  third  of  the 
leg,  is  nearly  always  done  in  preference.  Arthrectomy  however, 
where  the  bones  are  not  extensively  diseased,  may  be  tried  before 
resorting  to  the  above  procedures. 


Line  of  incision  in  the  circular 
division  of  the  femur  for  anky- 
losis of  the  knee  in  the  semi- 
flexed position.  A,  line  of 
incision;  BC, line  of  epiphysis. 


DISEASES   OF   MUSCLES. 


Inflammaiion  and  ABSCESS.  —  Inflammation  of  muscle,  or 
myositis,  may  be  due  to  a  sprain,  partial  rupture,  or  other  slight 
injury,  or  to  rheumatism  or  pyasmia,  or  it  may  spread  to  the 
muscle  from  the  surrounding  tissues.  Except  in  the  pysemic  form 
it  generally  ends  in  resolution.  Signs. — Pain,  swelling,  rigidity, 
and  more  or  less  fever,  followed   by  signs  of  an  abscess  should 


•      DISEASES   OF   TENDONS.  26 1   . 

suppuration  ensue.  Treatment- — Rest,  an  anodyne  liniment,  or 
a  belladonna  plaster  to  assuage  pain,  and  a  free  incision  if  pus 
forms. 

GuMMATA  may  be  met  with  in  muscle  in  the  tertiary  stages  of 
syphilis.  They  are  said  to  be  especially  common  in  the  sterno- 
mastoid  of  infants,  the  subjects  of  congenital  syphilis  ;  but  it  is 
probable  that  many  of  the  localized  swellings  in  the  sterno-mastoid 
of  infants  are  due  to  partial  rupture  during  birth. 

Atrophy  and  degenerai  ion  of  muscle  merely  require  mention. 
The  chief  degenerations  are — i,  simple  atrophy;  2,  fatty  de- 
generation ;  3,  granular  degeneration  ;  and,  4,  waxy  or  vitreous 
degeneration.  In  simple  atrophy  the  muscles  merely  waste,  but 
do  not  lose  their  striation,  and  are  capable  of  being  restored  to 
their  normal  condition;  whereas  the  fibres  of  a  degenerated 
muscle  are  altered  in  their  anatomical  structure,  and  their  func- 
tion is  entirely  and  permanently  lost.  Simple  atrophy  may  occur 
from  many  causes.  It  is  generally  seen  in  surgical  practice  as  the 
result  of  long  disuse  of  a  limb,  as  in  chronic  joint,  disease,  but  it 
is  then  usually  associated  with  some  amount  of  degenerative 
change.  Fatty,  granular,  and  waxy  degeneration,  though  some- 
times m.et  with  singly,  are  more  often  found  combined  in  the 
same  muscle.  They  occur  in  acute  febrile  diseases,  scrivener's 
.palsy,  progressive  muscular  atrophy,  infantile  paralysis,  pseudo- 
hypertrophic paralysis,  etc. 

Hypertrophy  of  muscle  calls  for  no  special  remark.  A  familiar 
example  of  hypertrophy  of  the  voluntary  muscles  is  seen  in  the 
hmbs  of  athletes ;  of  hypertrophy  of  the  involuntary  muscles,  in 
the  muscular  coat  of  the  bladder,  which  has  become  thickened  in 
its  efforts  to  overcome  the  obstruction  of  a  stricture. 

Ossification  of  muscle  may  occur  as  the  result  of  chronic  irri- 
tation. As  examples  may  be  mentioned  the  rider''s  bone,  or 
ossification  of  the  adductors,  occasionally  met  with  in  persons  who 
ride  a  great  deal ;  the  drill  bone,  or  ossification  of  the  deltoid  in 
soldiers  as  the  result  of  shouldering  arms ;  and  the  ossification  of 
the  rectus  and  other  muscles  in  Charcot's  disease  of  the  joints. 

Tumors. — Although  primary  tumors  are  not  common  in  muscle, 
nearly  all  varieties  except  carcinoma  have  at  times  been  met  with. 
Sarcoma  occurs,  perhaps,  the  most  frequently. 

diseases  of  tendons. 

Simple  teno-synovitis  or  inflammation  of  the  sheath  of  a  ten- 
don, may  be  acute,  subacute,  or  chronic.  It  is  most  frequently 
met  with  in  the  subacute  form  and  in  the  extensors  of  the  thumb 
and  wrist  as  the  result  of  over-exertion — a  hard  day's  rowing,  and 


262^  DISEASES    OF    SPECIAL   TISSUES. 

the  like.  In  this  situation,  it  produces  an  elongated  swelling  over 
the  extensors  of  the  thumb,  and  is  attended  with  pain  on  pressure 
and  movement,  and  a  characteristic  creaking  sensation.  In  the 
acute  form  suppuration  may  occasionally  occur.  TreatJiient. — : 
Rest  on  a  splint,  painting  with  tincture  of  iodine  and  strapping 
will  generally  suffice.  In  the  acute  variety,  leeches,  of  free  in- 
cision if  pus  forms,  and  passive  movements  to  prevent  adhesions. 
In  the  chronic,  counter-irritation  in  the  form  of  blisters,  and  pres- 
sure by  means  of  strapping,  followed  by  elastic  support. 

Ganglion  is  a  simple  or  compound  cyst  formed  in  connection 
with  the  sheath  of  a  tendon.  It  is  generally  due  to  .continued 
strain  or  teno-synovitis.    A  simple  ganglion  may  be  produced  by — 

1,  the  cystic  transformation  of  the  cells  in  the  synovial  fringes; 

2,  the  dilatation  of  the  sub-synovial  follicles  ;  and  3,  the  pouch-like 
protrusion  of  the  synovial  lining  of  the  tendon  through  the  fibrous 
sheath,  with  the  subsequent  obliteration  of  the  neck  of  the  pouch. 
Simple  ganglia  are  most  common  on  the  extensor  tendons  at  the 
back  of  the  wrist,  but  occur  in  other  situations,  as  the  front  of  the 
wrist  and  ankle,  and  on  the  sheaths  of  the  flexor  tendons  near 
the  web  of  the  fingers.  They  form  smooth,  generally  globular, 
often  translucent,  tense  or  semi-fluctuating  movable  swellings, 
evidently  in  connection  with  a  tendon,  and  varying  in  size  from  a 
pea  to  a  pigeon's  egg.  They  contain  a  clear  jelly-like  fluid.  The 
only  inconvenience  to  which  they  give  rise  is  a  feeling  of  weakness" 
in  the  wrist  or  fingers;  they  are  seldom  attended  with  pain.  Sim- 
ple ganglia  are  sometimes  simulated  by  pouch-like  protusions  of 
the  synovial  membrane  of  the  carpus  and  tarsus.  The  deep  attach- 
ment of  these  synovial  pouches,  their  non-connection  with  a  tendon, 
and  the  concomitant  swelling  of  other  parts  of  the  synovial  mem- 
brane, are  points  which  may  serve  to  distinguish  them.  Treatment. 
— They  may  often  be  broken  by  pressure  with  the  thumbs  ;  other- 
wise they  may  be  punctured  with  a  tenotome,  the  skin  being  drawn 
aside  to  make  the  opening  valvular,  and  the  contents  squeezed 
out.  In  either  case  firm  pressure  must  subsequently  be  applied  by 
strapping  and  a  bandage.  Should  they  refill,  a  second  puncture 
may  be  made,  and  the  interior  scarified  by  the  point  of  the  teno- 
tome. This  failing,  the  cyst  may  be  laid  open  and  allowed  to 
granulate  from  the  bottom,  or  it  may  be  dissected  out. 

A  compound ganglio)}  consists  of  the  dilatation  of  the  sheath  of 
several  tendons.  It  is  most  common  in  connection  with  the  flexor 
tendons  where  they  pass  under  the  anterior  annular  ligament  of 
the  wrist,  and  is  then  spoken  of  as  the  palmar  luirsal ganglion. 
The  walls  frequently  become  thickcnerl  and  villous-like  on  their 
internal  surface,  wVxX'fX  mclon-seed-like  bodies  are  frequently  found 
free  in  the  interior  of  the  ganglion  or  attached  by  slender  pedun- 


PAROm:'CHIA   TENDINOSA.  263 

cles  to  its  walls.  The  fluid  contained  in  the  cyst  may  be  clear  and 
serous,  or  thick  and  gelatinous,  and  of  a  dark  chocolate  color. 
These  ganglia  have  lately  been  described  as  arising  from  a  tuber- 
culous degeneration  of  the  sheaths  of  the  tendons,  similar  to  pulpy 
degeneration  of  a  joint,  and  the  tubercle  bacillus  has  been  found 
in  them.  S/g/is. — A  palmar  barsal  ganglion  forms  a  tense  elastic 
swelling,  constricted  at  its  centre  by  the  anterior  annular  ligament. 
The  swelling  projects  both  in  the  wrist  and  in  the  palm,  and  occa- 
sionally extends  along  the  flexor  tendons  of  the  thumb  and  little 
finger.  Fluctuation  may  be  obtained  by  pressing  alternately 
above  and  below  the  annular  ligament.  Operative  {reatinent\v3& 
formerly,  and  is  now  if  strict  antiseptic  precautions  are  not  taken, 
attended  with  some  risk — such  as  stiff  wrist  or  fingers  from  the 
gluing  together  of  the  tendons,  suppuration  extending  up  the 
planes  of  the  flexor  muscles  into  the  forearm,  acute  cellulitis,  ery- 
sipelas, saprremia  and  pyaemia.  An  operation,  therefore,  should 
only  be  undertaken  when  necessitated  by  loss  of  power  in  the 
wrist  or  fingers,  and  even  then  not  until  an  attempt  has  been  made 
to  cure  the  gangUon  by  pressure,  strapping,  and  counter- irritation. 
Should  an  operation  become  requisite,  it  is  best,  in  my  opinion,  to 
make  an  antiseptic  incision  above  and  below  the  annular  ligament, 
squeeze  out  the  melon  seed  bodies  and  insert  a  drain-tube.  If 
this  is  done  before  suppuration  has  taken  place,  recovery  with 
complete  movement  may  generally  be  obtained.  The  forearm 
and  hand  should  be  confined  on  a  sphnt. 

Paronychia  tendinosa,  a  variety  of  whitlow,  is  an  acute  infec- 
tive inflammation  of  the  sheath  of  a  tendon,  generally  of  a  finger, 
more  rarely  of  a  toe.  It  is  usually  the  result  of  inoculation  with  a 
septic  or  infective  poison  in  a  person  who  is  out  of  health.  It  may 
begin  in  the  sheath  of  the  tendon,  or  in  the  tissues  superficial  to 
the  sheath,  or  in  the  periosteum  of  the  phalanx.  If  neglected, 
very  serious  consequences  may  ensue  ;  thus,  i,  the  tendon  may 
die  from  its  blood-supply  being  cut  off  by  the  inflammatory  effu- 
sion ;  2,  the  suppuration  may  extend  into  the  palm,  and  under 
the  annular  ligament  into  the  forearm  ;  3,  the  inter-phalangeal, 
carpal,  or  wrist  joint  may  become  involved  in  the  inflammation 
and  destroyed  ;  4,  the  phalanx  may  necrose  ;  5,  septicaemia  or 
pyaemia  may  ensue.  Signs. — Intense  and  throbbing  pain,  acute 
tenderness  on  pressure,  and  swelling  and  induration  of  the  finger, 
followed  by  a  similar  condition  of  the  palm,  and  often  by  great 
oedema  of  the  back  of  the  hand,  which  may  perhaps  extend  up  the 
forearm.  The  lymphatics  may  become  tender  and  inflanied,  and 
the  lymphatic  glands  in  the  axilla  enlarged.  Exhaustion  from  pain 
and  want  of  sleep,  feverish  symptoms,  and  at  times  signs  of  blood- 
poisoning,  may  ensue.     Diagnosis. — Acute  septic  inflammation 


264  DISEASES   OF    SPECIAL   TISSUES. 

of  the  pulp  of  the  finger  is  very  apt  to  be  mistaken  for  true  thecal 
whitlow.  The  diagnosis  of  these  two  conditions  is  most  import- 
ant, since  in  the  former  affection  if  free  incisions  are  made 
into  the  inflamed  part,  leaving  the  tendon  sheath  intact,  the 
tendon  will  be  saved,  whereas,  if  the  affection  is  mistaken  for 
thecal  abscess,  and  the  sheath  opened,  the  septic  material  will  in- 
vade the  sheath  and  the  tendon  will  probably  be  destroyed.  The 
history  of  the  case  and  the  severity  of  the  symptoms  will  guide  us 
somewhat,  but  perhaps  the  most  important  sign  in  distinguishing 
the  two  affections  is  one  pointed  out  by  Mr.  Morrant  Baker,  viz. : 
"  the  power  or  the  loss  of  it  on  the  part  of  the  patient  of  flexing 
voluntarily  the  distal  phalanx."  In  true  thecal  whitlow  this  povver^ 
is  much  impaired  or  lost,  whilst  in  mere  septic  inflammation  of  the 
pulp,  although  the  finger  may  appear  hopelessly  spoiled,  it  is 
"  markedly  and  strongly  retained."  Treatment. — The  chief  indi- 
cation is  to  relieve  tension,  and  thus  prevent  the  strangulation  of 
the  vessels  and  consequent  death  of  the  tendon,  and  the  spread  of 
the  inflammation  into  the  palm  or  to  the  periosteum  covering  the 
phalanx.  For  this  purpose,  a  free  incision  is  generally  recom- 
mended in  the  middle  line  of  the  finger  extending  into  the  sheath, 
or  to  the  bone  if  the  periostem  is  affected.  Mr.  Heath,  however, 
advises  that  the  incisions  should  be  made  at  the  side  of  the  finger, 
but  should  not  in  this  position  open  the  sheath,  since  if  this  is 
done  he  says  the  tendon  invariably  sloughs.  He  opens  the  sheath 
by  a  small  incision  through  the  palm  over  the  head  of  the  meta- 
carpal bone.  Should  suppuration  occur  in  the  forearm  the  pus  of 
course  must  be  let  out  by  timely  incisions.  The  pain  in  the  mean- 
while will  be  greatly  relieved  by  placing  the  whole  forearm  for 
several  hours  at  a  time  in  a  bath  kept  at  a  temperature  as  high  as 
can  be  borne.  Corrosive  sublimate  or  carbolic  acid  should  be 
added  to  the  water.  A  purge  at  the  onset  is  generally  required, 
and  opium  is  usually  needed  to  relieve  the  pain.  The  patient  at 
first  should  be  confined  to  a  slop  diet,  but  later  a  stimulating  plan 
of  treatment  is  commonly  called  for.  Should  any  stiffness  of  the 
part  remain  after  the  inflammation  has  subsided,  an  attempt  should 
be  made  to  overcome  it  by  passive  movements,  massage,  etc. 
Dead  bone  must  be  removed  when  loose,  and  am[)utation  of  the 
affected  finger,  or  even,  in  severe  cases,  of  the  forearm,  may  be- 
come necessary. 

DISEASES   OF   FASCIA. 

Dupuytrf.n's  contkactiom  of  the  palmar  fascia  is  the  only 
affection  of  the  fasciae  requiring  notice.  It  has  been  attributed 
to  gout  and  rheumatism,  and  to  habits  or  occupations  necessi- 
tating pressure  in  the  palm,  or  flexion  of  the  fingers.     It  is  prob- 


DISEASES   OF   BURS^. 


265 


Fig.  90. 


ably  of  the  nature  of  a  chronic  inflammation,  secondary,  according 
to  Mr.  Anderson,  to  inoculation  of  the  subcutaneous  connective  tis- 
sue with  a  specific  germ,  which  he  suggests  might  gain  admission 
by  a  scratch  of  the  palm  by  the  finger-nail.  The  affection  consists 
in  a  shortening  of  the  prolongations  of  the  fascia  from  the  palm 
on  to  the  sheath  of  the  flexor  tendons.  The  tendons  themselves 
are  not  afl'ected.  The  contraction  generally  begins  in  the  fascia 
of  the  little  or  ring  finger  as  a  small  rounded  fibrous  nodule,  and 
always  at  a  point  where  a  wound  from  the  nail  with  the  finger 
clenched  might  occur,  and  later  may  affect  that  of  the  middle 
finger,  and  at  times  the  forefinger  and  also  the  thumb.  The 
affected  fingers  (Fig.  90)  are  drawn  by  tense  bands  towards  the 
palm,  and  in  severe  cases  may  become  fixed  in  contact  with  it. 
The  skin  being  adherent  to  the  fascia,  is  thrown  thereby  into 
transverse  puckers.  The  affection  may  be  distinguished  from  a 
contracted  tendon  by  the  latter  forming  a 
tight  cord,  which  can  be  traced  under 
the  annular  ligament,  and  by  the  skin  in 
the  case  of.  the  contracted  tendon  being 
free.  In  contraction  of  the  fascia,  more- 
over, two  tense  bands  can  generally  be 
traced  to  the  sides  of  the  finger,  whereas 
a  contracted  tendon  is  centrally  placed. 

Treatment. — Except  in  the  early  stages, 
when  steps  should  be  taken  to  prevent 
further  contraction  by  suitable  splints, 
elastic  tension,  etc.,  subcutaneous  division 
of  the  affected  portions  of  the  fascia, 
followed  by  extension,  or  the  excision  of 
the  contracted  band  through  an  open 
aseptic  incision  {Thiersch'' s  method)  is 
requisite.  Subcutaneous  division  may  be 
done  by  single  or  by  multiple  puncture. 
The  latter  is,  in  my  opinion,  preferable  if 
the  subcutaneous  method  is  adopted. 
The  punctures  should  be  made  opposite  the  puckers  in  the  skin, 
not  in  the  creases,  to  prevent  the  wounds  from  gaping  when  the 
fascia  is  stretched.  An  apparatus  should  be  worn  for  many 
months  to  prevent  recontraction.  In  severe  cases  I  have  ob- 
tained excellent  results  by  the  open  incision.  After  this  method, 
moreover,  there  is  less  liability  to  recontraction. 


Dupuytren's  contraction  of 
the  palmar  fascia.  (From 
a  cast  in  St.  Bartholomew's 
Hospital  Museum.; 


DISEASES   OF    BURS/E. 


BuRS.(E,  wherever  situated,  and  whether  existing  naturally  or 
12 


2  66  DISE.4SES   OF   SPECIAL   TISSUES. 

formed  adventitiousl}',  are  liable  to  become  acutely  or  chronically 
inflamed. 

Acute  bursitis  may  occur  spontaneously,  but  is  generally  ex- 
cited by  injury,  or  undue  pressure  as  from  constant  kneeling. 
The  inflammation  comes  on  rather  suddenly,  the  part  appearing 
red,  hot,  and  swollen.  It  is  apt  to  terminate  in  suppuration, 
which  if  timely  incisions  are  not  made  may  become  diffuse  and 
phlegmonous.  Evaporating  lotions,  an  ice-bag  or  a  few  leeches, 
may,  if  applied  early,  check  the  inflammation ;  but  a  free  incision 
must  be  made  as  soon  as  there  are  signs  of  suppuration. 

Chromc  bursitis  is  very  apt  to  occur  in  burs^  that  are  sub- 
jected to  continued  pressure  or  irritation,  and  may  lead  to  several 
distinct  conditions.  Thus,  i.  Buiscb  may  become  simply  enlarged 
and  distended  wilh  bursal  secretion.  In  this  state  they  form 
globular,  fluctuating,  often  translucent,  tense  or  flaccid  swellings; 
their  walls  are  but  slightly  thickened  ;  and  there  is  no  heat  or  red- 
ness of  the  skin.  2.  77;.?;'  tnay  become  enlarged,  slightly  thickened, 
and  distended  with  a  serous  or  dark  fluid  containing  small  masses 
of  fibrin  resembling  melon-seeds.  These  melon-seed  bodies  may 
be  formed  from  extravasated  blood,  fibrinous  deposits,  or  detached 
portions  of  thickened  synovial  fringes,  and  their  presence  may 
sometimes  be  detected  by  the  crackling  sensation  they  give  when 
the  bursa  is  handled.  Sometimes  in  place  of,  or  together  with, 
melon-seed  bodies,  fibrous  cords  are  found  stretching  across  the 
cavity  of  the  bursa.  3.  They  may  become  enlarged  and  their  walls 
greatly  thickened  by  inflammatory  infiltration  and  the  deposit  of 
fibrin  in  their  interior.  A  small  central  cavity  may  remain,  or 
they  may  be  solid  throughout.  They  then  appear  as  firm,  non- 
elastic,  solid-feeling  tumors,  and  when  situated  over  the  tuberosity 
of  the  ischium,  or  in  front  of  the  patella,  may  cause  much  incon- 
venience. 

Treatmeiit. — When  simply  enlarged,  painting  with  the  liniment 
of  iodine,  or  strapping,  will  sometimes  disperse  them.  If  this  fails 
they  should  be  punctured,  the  fluid  evacuated,  the  melon-seed 
bodies,  if  present,  squeezed  out,  and  firm  pressure  applied.  When 
greatly  thickened  or  solid  they  must  be  disserted  out. 

The  situations  in  which  these  various  conditions  of  the  bursse 
are  most  frequently  met  with  are  : — over  the  patella,  the  house- 
?naid's  knee;  over  the  olecranon,  the  minei-'s  bursa;  over  the 
tuber  ischii,  the  weaver's  bottom  or  coachman  s  bursa ;  over  the 
great  trochanter;  under  the  semi-membranosus ;  and  under  the 
psoas  tendon.  Adventitious  bursas  may  also  be  found  under  corns 
or  over  points  of  bone  subjected  to  pressure,  as  the  metatarso- 
phalangeal joint  of  the  great  toe  {bunion),  the  outer  side  of  the 
-foot  in  talipes  varus,  etc.     (See  Hallux  Valgus  and  Talipes.) 


CHRONIC   ARTERITIS.  267 

The  bursa  patellcE  is  the  one  which  is  most  frequently  affected, 
and  what  has  been  said  about  diseases  of  bursae  in  general  applies 
particularly  to  it.  When  acutely  and  diffusely  inflamed  it  may 
simulate  disease  of  the  knee-joint,  from  which,  however,  it  may 
readily  be  diagnosed  by  the  swelling  in  the  one  case  being  in 
front  of  the  patella  and  in  the  other  behind  it.  A  few  words  may 
also  be  added  concerning  the  bursa  beneath  the  seini-membran- 
osus.  When  enlarged  it  forms  a  tense  or  semi-fluctuating  ovoid 
swelling  in  the  popliteal  space,  but  becomes  flaccid  or  disappears 
altogether  on  flexing  the  knee.  Counter-irritation  or  pressure 
will  generally  disperse  it.  If  these  fail  it  may  be  punctured  or 
incised  and  drained  antiseptically ;  but  the  greatest  precaution 
must  be  taken  to  prevent  septic  changes  occurring,  as  it  often 
communicates  with  the  knee-joint.  Indeed,  I  have  seen  several 
cases  in  which  acute  suppuration  in  the  knee,  necessitating  am- 
putation, has  followed  the  incautious  puncture  of  these  bursae. 
The  safest  course  perhaps  is  to  dissect  out  the  bursa,  ligature  the 
pedicle  by  which  it  communicates  with  the  knee-joint,  and  cut 
the  rest  away. 

DISEASES  OF  THE  ARTERIES. 

Arteritis  or  inflammation  of  the  arteries  may  be  acute  or 
chro7iic. 

Acute  arteritis  was  formerly  thought  to  be  of  frequent  occur- 
rence as  an  idiopathic  affection,  but  as  such  it  is  now  known  not 
to  exist.  Acute  traumatic  arteritis,  however,  is  very  common, 
occurring  as  it  does  in  the  simple  ox  plastic  form  in  the  process  of 
healing  of  an  artery  after  injury  or  hgature,  or  from  the  presence 
of  a  non-infective  thrombus  ;  whilst  as  a  septic,  infective  or  sup- 
purative affection  it  is  occasionally  met  with  as  the  result  of  the 
extension  of  septic  or  infective  inflammation  to  an  artery  from 
the  surrounding  tissues,  or  as  the  result  of  the  presence  of  a  sep- 
tic or  infective  embolus  brought  by  the  blood-stream  from  a  Hke 
inflammation  of  a  distant  part,  as  the  heart  in  ulcerative  endo- 
carditis. Plastic  or  adhesive  arteritis  has  already  been  discussed 
under  the  Healing  of  Arteries.  Of  septic  and  infective  arteritis  all 
that  need  be  said  here  is  that  when  due  to  extension  from  the 
surrounding  tissues  it  may  lead  to  the  softening  and  giving  way 
of  the  arterial  walls,  and,  unless  a  clot  forms  above  and  below,  to 
haemorrhage  ;  whilst  when  due  to  an  embolus  it  may  lay  the 
foundation  of  an  aneurysm,  or,  more  rarely,  may  lead  to  the 
rupture  of  the  vessel.  It  is  believed  to  be  the  chief  cause  of 
aneurysm  in  children. 

Chronic  arteritis,  familiarly  known  as  atheroma,  mainly  affects 
the  deeper  layers  of  the  intima,  not,  as  a  rule,  the  other  coats. 


2  68  DISEASES   OF   SPECIAL  TISSUES. 

Hence  it  is  often  spoken  of  as  endarleritis.  It  is  the  commonest 
disease  of  the  arteries,  and  to  some  extent  is  generally  present  in 
persons  over  forty.  It  is  most  frequent  in  the  aorta  and  large 
vessels,  that  is,  in  those  containing  the  greatest  amount  of  yellow 
elastic  tissue,  and  is  more  often  met  with  in  the  arteries  of  the 
lower  than  in  those  of  the  upper  limb. 

Causes. — Mechanical  strain  or  vascular  tension  is  looked  upon 
as  the  most  frequent  exciting  cause.  Thus  it  is  attributed  to — i, 
occupations  necessitating  severe  and  prolonged  exertion;  2,  the 
abuse  of  alcohol,  which  produces  an  increased  and  forcible  action 
of  the  heart ;  3,  chronic  Bright's  disease,  in  which  the  blood- 
pressure,  in  consequence  of  capillary  fibrosis  or  spasm  of  the 
arterioles,  is  increased ;  4,  plethora,  in  which  the  arterial  tension 
is  also  raised  ;  5,  syphilis,  which  is  attended  by  fibroid  change  in 
the  small  vessels  and  consequent  increased  vascular  tension  ;  and 
6,  gout,  in  that  it  may  produce  Bright's  disease.  In  addition, 
however,  to  the  increased  vascular  tension,  to  which  the  above- 
mentioned  conditions  may  give  rise,  gout,  syphilis,  and  alcohol 
may  also  lead  to  the  primary  degenerative  changes  in  the  coats  of 
the  arteries  in  common  with  the  degenerations  they  induce  in  the 
tissues  generally  throughout  the  body,  and  hence,  together  with 
advancing  age,  and  the  male  sex,  men  being  more  exposed  to 
mechanical  strains  than  women,  may  be  looked  upon  as  predis- 
posifjg  as  well  as  exciting  causes. 

Pathology. — Arteritis  begins  as  a  small  round-cell  infiltration  of 
the  deeper  layers  of  the  intima — those  next  the  muscular  coat. 
This  gives  rise  to  characteristic  greyish-white,  slightly  elevated, 
tough,  semi-gelatinous  patches  on  the  inner  surface  of  the 
vessel.  The  patches,  which  frequently  begin  around  the  entrance 
of  small  lateral  branches,  increase  by  their  edges,  and  by  coales- 
cing with  other  patches  produce  extensive  tracts  of  the  disease. 
The  inflammatory  infiltration  in  consequence  of  the  absence 
of  new  vessels,  may  undergo — i,  fatty;  2,  calcareous;  or  3, 
fibroid  degeneration,  i.  The  patches  formerly  gray  become 
yellowish-white,  breaking  down  into  a  cheesy  mass  or  com- 
pletely liquefying  into  a  puriform  fluid  consisting  of  fatty  debris, 
cholesterine-crystals,  and  minute  oil-droi)S.  The  layers  of  the 
intima  next  the  blood  are  at  first  continued  unbroken  over  the 
fatty  patch,  which  is  then  called  an  aiJierornaious  abscess.  These 
layers,  however,  may  subsequently  give  way,  leaving  the  softened 
and  fatty  mass  in  contact  with  the  blood  (the  atherojnatous  uicer). 
Portions  of  the  fatty  material  may  now  be  washed  away  by  the 
blood-stream  and  become  lodged  in  some  of  the  smaller  arteries 
and  capillaries,  where  they  seldom,  however,  do  any  harm,  as  the 
emboli  are  non-infective.     At  times,  however,  a  larger  vessel  may 


OBLITERATIVE   ARTERITIS.  269 

become  plugged,  when  gangrene  may  ensue.  As  the  atheroma- 
tous material  is  washed  away  by  the  blood,  fibroid  thickening  of 
the  external  coat  and  sheath  of  the  artery  takes  place  opposite 
the  base  of  the  ulcer,  so  preventing  perforation  of  the  artery  ;  but 
as  the  new  tissue  is  very  inelastic  it  is  liable  to  yield  to  the  pressure 
of  the  blood  and  an  aneurysm  occur.  2.  Instead  of  the  patch 
undergoing  fatty  softening,  lime  salts  may  be  deposited  in  it. 
This  secondary  calcification  must  be  distinguished  from  the 
primary  calcification  to  be  shortly  mentioned.  The  intima  may 
be  continued  over  the  calcareous  patch,  or  it  may  break  away, 
leaving  it  exposed  to  the  blood  current,  thus  constituting  a  nidus 
for  the  deposition  of  fibrin  and  the  formation  of  a  thrombus,  por- 
tions of  which  again  in  their  turn  may  be  washed  away  by  the 
blood  and  form  emboli.  3.  The  small-cell  infiltration  in  the  in- 
flamed patch  instead  of  undergoing  either  of  the  former  changes 
may  advance  to  the  production  of  fibrous  tissue,  and  a  dense 
fibroid  thickening  result. 

The  ejfects  of  chronic  arteritis. — i.  The  artery  may  become  di- 
lated, elongated,  and  tortuous ;  2,  it  may  yield  at  the  atheroma- 
tous patch,  producing  an  aneurysm  ;  and  3,  it  may  rupture  under 
violence.  In  addition  to  the  above  effects  depending  upon  the 
loss  of  elasticity  of  the  vessel,  thrombosis  and  embolism  may  oc- 
cur, as  already  stated,  and  give  rise  to  gangrene,  aneurysm,  or 
rupture. 

Signs. — Except  in  the  superficial  vessels,  where  atheroma  is 
productive  of  rigidity  and  a  tortuous  condition  of  the  artery,  it 
gives  no  special  evidence  of  its  presence. 

Syphilitic  arteritis  is  the  term  applied  to  a  fibroid  change 
occurring  chiefly  in  the  smaller  arteries  during  the  later  stages  of 
syphilis.  It  is  most  common  in  the  arteries  of  the  brain.  The 
change  consists  in  an  extensive  infiltration  of  small  round  cells, 
which  later  become  developed  into  an  imperfect  fibrous  tissue. 
The  inner  coat  is  chiefly  affected  and  becomes  greatly  thickened, 
so  that  the  lumen  of  the  vessel  is  almost  or  entirely  obliterated. 
The  outer  coat  is  likewise  implicated,  but  to  a  less  extent,  while 
the  muscular  coat  either  escapes  or  is  merely  encroached  upon 
by  the  cells  infiltrating  the  inner  coat.  The  disease  is  very 
chronic,  and  may  terminate  in  thrombosis,  or  may  lead  to  the 
formation  of  an  aneurysm. 

Oeliterative  arteritis,  so  called,  is  a  rare  disease,  charac- 
terized by  great  pain  spreading  up  the  course  of  the  artery,  loss 
of  pulse  in  the  vessel,  and  often  gangrene  of  the  part  supplied  by 
it.  Its  pathology  is  not  known,  but  there  is  evidence  that  points 
to  its  depending  more  on  some  nerve  change  than  on  an  inflam- 
mation of  the  artery  itself. 


270 


DISEASES   OF   SPECIAL   TISSUES. 


Primary  degeneration  of  arteries. — We  have  already  seen 
that  fatty,  calcareous,  and  fibroid  degeneration  may  follow  chronic 
endarteritis.  These  changes  may,  however,  occur  as  primary 
affections,  and  may  next  be  considered. 

Primary  fatty  degeneration  begins  in  the  superficial  layers  of 
the  intima,  immediately  under  the  endothelium.  It  takes  the 
form  of  yellowish-white  patches,  very  slightly  projecting  into  the 
vessel.  The  patches  can  be  readily  stripped  off  from  the  deeper 
layers,  which,  when  thus  exposed,  are  found  healthy  ;  whereas,  in 
atheroma,  it  is  the  deeper  layers  which  are  the  seat  of  the  disease. 
The  disease  is  attended  with  no  signs,  and  is  of  little  practical 
interest. 

Primary  calcification  is  of  more  importance.  It  should  be  dis- 
tinguished from  calcification  occurring  as  a  second- 
FiG.  91.  ary  change  in  endarteritis.  Primary  calcification 
begins  in  the  circular  muscular  fibres  of  the  middle 
coat,  and  is  more  common  in  the  smaller  than  in  the 
larger  arteries,  and  in  those  of  the  lower  than  in 
those  of  the  upper  extremity.  It  is  a  disease  of  ad- 
vancing age,  and  is  a  frequent  cause  of  senile  gan- 
grene in  that  the  arteries  are  converted  into  rigid 
tubes  and  the  circulation  through  them  is  in  conse- 
quence greatly  impeded.  Thrombosis,  moreover,  is 
very  liable  to  occur.  In  primary  calcification  the 
lime  salts  are  deposited  in  the  form  of  rings  (Fig. 
91)  instead  of  in  irregular  patches  as  in  secondary 
calcification. 

Fibroid  degeneration. — For  a  description  of  this  a 
work  on  Medicine  must  be  consulted. 


J 


Primary  calci- 
fication o  f 
arteries.  (St. 
B  a  r  I  h  o  1  o- 
mew'  Hospi- 
tal  Muse- 
um.) 


ANEURYSM. 


An  aneurysm  is  a  tumor  containing  blood,  and 
communicating  with  the  interior  of  an  artery.  Aneu- 
rysms may  be  divided  into  two  main  classes,  the 
spontaneous,  which  are  the  result  of  disease  of  the 
vessel-walls,  and  the  traumatic,  which  are  due  to  a  direct  injury 
of  the  artery  and  extravasation  of  blood  into  the  tissues.  Here 
the  spontaneous  only  will  receive  attention.  The  traumatic  are 
described  under  Injuries  of  Arteries  (p.  201). 

Spontaneous  aneurysm. —  Cause. — Aneurysms  are  most  common 
at  that  age  when  the  coats  of  the  arteries  are  liable  to  be  weak- 
ened by  disease  whilst  the  muscular  system  is  still  vigorous,  and 
are  chiefly  met  with  among  those  whose  occupations  subject  them 
to  sudden  or  irregular  strams.     Hence,  the  frequency  with  which 


SPONTANEOUS   ANEURYSM.  27 1 

they  occur  in  soldiers,  sailors,  and  the  laboring  classes,  and  in 
men  rather  than  in  women.     The  chief  predisposing  causes  are — 

1,  atheroma,  whereby  the  coats  of  the  artery  are  softened  and 
unable  to  resist  an  increased  expansile  pressure  of  the  blood  ;  and 

2,  embolism,  which  may  lead  to  inflammatory  changes,  and  con- 
sequent weakening  of  the  arterial  walls  immediately  above  the 
embolus.  Thus  the  conditions  which  induce  atheroma  and  em- 
bolism may  also  be  considered  as  predisposing  causes  of  aneurysm. 
Of  these,  however,  syphihs,  the  abuse  of  alcohol,  continued  vas- 
cular strain,  and  ulcerative  endocarditis  may  be  especially  men- 
tioned. Syphihs  is  by  far  the  most  common  cause  of  aneurysm  in 
women.  The  exciting  causes  are  such  as  produce  the  rupture  or 
yielding  of  the  diseased  coats,  either  {a)  by  direct  mechanical 
violence,  or  {b')  by  increased  blood-pressure  in  the  vessel  owing 
to  violent  and  sudden  action  of  the  heart  and  obstruction  by 
muscular  contraction  of  the  capillary  flow.  Hence,  blows  or 
strains,  mental  emotion,  and  violent  and  sudden  exertion  of  all 
kinds  may  be  mentioned  as  exciting  causes. 

Process  of  formation. — An  aneurysm  may  be  formed  in  several 
ways  : — i.  By  the  simple  dilatation  of  a  diseased  portion  of  an 
artery  due  to  the  yielding  of  the  softened  coats  to  the  expansile 
force  of  the  blood  current.  2.  By  the  giving  way  of  the  internal 
and  middle  coats  at  the  diseased  spot,  and  the  yielding  of  the 
external  coat  to  the  force  of  the  blood.  This  is  the  commonest 
way  in  which  an  aneurysm  is  formed — the  elastic  fibres  of  the 
internal  coat  as  the  result  of  the  atheroma  soften  and  break  down, 
the  middle  coat  gives  way,  and  the  external  coat,  unable  to  resist 
the  blood  pressure,  is  bulged  out,  forming  the  sac  of  the  aneurysm. 

3,  By  the  giving  way  of  all  the  coats  at  the  diseased  spot  and 
escape  of  the  blood  into  the  tissues,  which  become  condensed 
around  it  to  form  a  sac.  4.  By  the  giving  way  of  the  external 
and  middle  coats,  and  the  protrusion  of  the  internal  coat  through 
them  (very  rare)  ;  and  5.  By  the  giving  way  of  the  internal  and 
part  of  the  middle  coats,  and  extravasation  of  the  blood  between 
the  layers  of  the  middle  coat. 

Structu7-e  of  an  anewysm. — An  aneurysm  consists  of  a  sac  and 
its  contents.  The  sac  may  consist — (i)  of  all  the  coats  of  the 
artery,  Fig.  92,  a  and  b  ;  (2)  of  the  external  coat  only,  Fig,  92,  c  ; 
(3)  of  condensed  tissues  external  to  the  artery.  Fig,  92,  f  ;  (4)  of 
the  internal  coat  only  (very  rare),  Fig.  92,  d  ;  (5)  of  the  separated 
layers  of  the  middle  coat,  between  which  the  blood  has  been 
forced,  with  the  external  and  internal  coats  on  either  side  (dis- 
secting aneurysm),  Fig.  92,  E.  The  practical  point,  however,  to 
be  borne  in  mind  is  that  it  is  only  whilst  the  aneurysm  is  small, 
and  then  by  dissection  alone,  that  these  distinctions  can  be  made  ; 


272 


DISEASES    OF    SPECIAL    TISSUES. 


and  that  as  the  aneurysm  increases  in  size  the  tissues  around  be- 
come condensed  and  blended  with  the  sac,  which  may  finally  be 
formed  almost  or  entirely  of  these  tissues.  The  contents  of  the 
sac. — When  an  aneurysm   is  first  formed,  the  sac  contains  only 

Fig.  92. 


Diagram  illustrating  the  structure  of  an  aneurysm. 

fluid  blood  ;  fibrin,  however,  is  gradually  deposited  from  the  blood 
in  concentric  layers  upon  the  internal  surface  of  the  sac,  so  that 
after  it  has  existed  some  time  the  contents  are  partly  solid  lami- 
nated fibrin,  and  partly  coagulated  and  fluid  blood.  Next  the 
wall  of  the  sac  the  fibrin  is  laminated,  firm  and  compressed,  and 
of  a  yellowish-white  color ;  but  towards  the  mouth  of  the  sac  it  be- 
comes softer  and  moister, 
F'<^'-  93-  and    of  a  reddish    color  ; 

whilst  that  in  contact  with 
the  fluid  blood  merely 
resembles  ordinary  blood 
coagulum.  In  an  aneu- 
rysm that  has  been  cured, 
the  whole  sac  will  gener- 
ally be  found  thus  filled 
with  laminated  clot,  which 
has  been  aptly  likened  to 
the  appearance  presented 
by  the  section  of  an  onion 
(  Fig.  93).  Where  the  cure 
has  taken  place  in  a  few 
hours,  it  is  probable  that 
the  greater  part  of  the 
material  filling  the  sac  is 
merely  blood  coagulum,  as 
in  such  instances  the  time 
would  ])robably  be  too 
short  for  fibrin  to  be  de- 
posited. 

Classification. — Spontaneous  aneurysms  may  be  divided  into 
the  fusiform,  the  sacculated,  and  the  dissecting. 


Laminated  appearance  of  the  clot  filling  a  consoli- 
flaled  aneurysm  of  the  arch  of  the  aorta.  iSi.  Har- 
tholomcw's  Hospital  Museum.) 


CLASSIFICATION.  2  73 

1.  A  fusiform  anetcn'sm  is  a  dilatation  of  the  whole  circumfer- 
ence of  a  portion  of  an  artery.  The  sac  consists  of  all  three 
coats,  and  is  continuous  with  the  lumen  of  the  artery  at  each  end 
(Fig.  92,  a).  The  dilated  portion  of  the  artery  is  also  elongated, 
as  is  well  seen  in  aneurysms  of  the  arch  of  the  aorta,  where,  in 
consequence  of  such  elongation,  the  three  primary  branches  are 
much  further  apart  than  normal  (Fig.  93).  Fusiform  aneurysms 
are  most  common  in  arteries  that  contain  much  yellow  elastic 
tissue,  as  the  aorta  and  its  primary  branches  and  the  contiguous 
portions  of  the  iUac  and  femoral  arteries.  They  often  attain  a 
large  size,  and  after  they  have  existed  some  time,  frequently  be- 
come sacculated  from  the  unequal  yielding  of  their  walls.  The 
walls  themselves,  though  sometimes  thinned,  are  more  often 
thickened,  and  are  highly  atheromatous.  Laminated  fibrin  is 
seldom  found  in  them,  as  the  circulation  does  not  as  a  rule  be- 
come sufficiently  retarded  to  allow  of  its  deposition. 

2.  A  sacculated  aneurysm  is  one  in  which  dilatation  occurs  in 
part  of  the  circumference  of  the  artery  only  (Fig.  92,  b,  c,  and 
d).  It  may  consist  of  all  three  coats  ;  but  much  more  often  the 
internal  and  middle  coats  give  way,  and  it  is  formed  of  only  the 
external  coat,  or  after  it  has  existed  some  time,  chiefly  of  the  con- 
densed cellular  tissue  around.  According  as  all  three  coats  are 
or  are  not  present,  the  aneurysm  was  formerly  spoken  of  as  triie 
or  false.  As,  however,  it  is  only  the  smallest  aneurysms  that  can 
consist  of  all  three  coats,  the  true  aneurysm  could  hardly  be  said 
ever  to  occur,  and  all  sacculated  aneurysms  were  then  called  false 
— the  absurdity  of  which  is  self-evident.  As  these  aneurysms  in- 
crease in  size,  the  sac  comes  to  consist  almost  entirely  of  the 
tissues  around.  Whilst  they  are  still  enclosed  by  one  of  the  coats 
of  the  artery,  they  are  sometimes  caUed  circumscribed,  and  after 
all  the  coats  have  given  way,  consecutive  or  diffused  (Fig.  92,  f). 
As  the  term  diffused,  however,  is  sometimes  applied  to  a  leaking 
or  ruptured  aneurysm,  it  had  better  be  discontinued.  Nearly  all 
sacculated  aneurysms,  when  they  have  existed  some  time,  are  of 
the  consecutive  variety,  and  usually  contain  a  considerable  amount 
of  laminated  fibrin. 

3.  A  dissecting  aneurysm  is  one  in  which  the  internal  coat  of 
the  artery  and  part  of  the  middle  coat  have  given  way,  and  the 
blood  has  been  forced  between  the  two  layers  of  the  middle  coat 
for  a  variable  distance  parallel  to  the  course  of  the  artery  (Fig. 
92,  e).  It  is  most  frequent  in  the  arch  and  thoracic  portion  of 
the  aorta.  The  blood  may  remain  between  the  layers  of  the 
middle  coat,  or  it  may  escape  through  a  rupture  of  the  external 
coat  into  the  tissues  around,  or  through  a  rupture  of  the  internal 
coat  lower  down  the  course  of  the  vessel  into  the  lumen  of  the 
artery. 


274 


DISEASES    OF    SPECIAL    TISSUES. 


Terminations. — An  aneurysm  may  terminate  in  spontaneous  re- 
covery or  in  death. 

Spontaneous  recovery  may  take  place: — A.  By  the  gradual  de- 
posit of  fibrin  from  the  blood  in  a  laminated  manner  on  the  walls 
of  the  sac,  so  that  the  aneurysm  is  completely  consolidated  (Fig. 
94,  a),  and  subsequently  by  condensation  and  shrinking  becomes 
conv'erted  into  a  small  nodular  mass  of  fibrous  tissue.  The  artery 
under  such  circumstances  may  remain  pervious,  or  become  con- 
verted into  a  fibrous  cord  as  far  as  the  first  collateral  branch 
above  and  below  the  seat  of  the  aneurysm.  Such  a  favorable 
termination  may  be  brought  about  by  the  retardation  of  the  blood 

current  induced  by — (i)  the 
Fig.  94-  lowering   of  the   heart's  ac- 

tion ;  (2)  the  pressure  of  the 
aneurysm  on  the  artery  above 
its  opening  into  the  sac  (Fig. 
94,  c)  ;  (3)  the/ar/Zci'/block- 
ing  of  the  mouth  of  the  sac 
with  a  piece  of  detached 
coagulum ;  (4)  the  impac- 
tion of  a  piece  of  clot  in  the 
artery  below  the  mouth  ot  the 
sac  (Fig.  94,  b)  ;  (5)  the 
pressure  of  another  aneurysm 
or  of  a  tumor  upon  the  artery 
above  the  sac  or  on  the  sac  it- 
self; (6)  the  aneurysm  rupturing,  and  the  effused  blood  compress- 
ing the  artery  leading  to  the  aneurysm,  b.  By  the  filling  of  the 
sac  with  ordinary  coagulum,  the  passive  clot  as  it  is  called,  in  con- 
tradistinction to  the  deposit  of  laminated  fibrin  {the  active  clot). 
This  coagulation  of  the  blood  in  the  sac  may  be  brought  about 
by — ( i)  the  complete  blocking  of  the  mouth  of  the  sac  by  a  piece 
of  detached  clot  (Fig.  94,  d),  or  (2)  the  complete  plugging  of 
the  artery  above  and  below  the  aneurysm.  The  clot  may  then 
undergo  the  ordinary  changes  that  occur  in  the  so-called  organ- 
ization of  blood-clot  and  be  converted  into  fibrous  tissue,  c.  By 
the  inflammation  and  sloughing  of  the  sac  and  the  plugging  of  the 
artery  above  and  below  with  clot  and  the  subsequent  changes  de- 
scribed under  the  spontaneous  arrest  of  haemorrhage. 

A  fatal  termination  may  be  brought  about  by — i,  rupture  of 
the  sac ;  2,  inflammation  and  sloughing  of  the  sac  attended  by 
haemorrhage  ;  3,  pressure  upon  important  parts  ;  4,  gangrene  due 
lo  the  obstruction  to  the  circulation  in  conse(iuence  of  the  large 
size  of  the  aneurysm,  or  to  the  jjlugging  of  a  large  vessel  by  a  por- 
tion   of   detached    clot;    5,  general   constitutional  disturbance. 


Diagram  to  show  methods  of  spontaneous  cure 
of  aneurysm.  A.  by  laminated  fibrin  {active 
clot),  v..  by  plugging  of  artery  below,  c.  by 
pressure  of  aneurysm  on  artery  above  mouth 
of  sac,  D.  by  plugging  of  mouth  of  sac  and 
formation  of  ordinary  coagulum  {/>ass!ve 
clot) . 


SYMPTOMS  AND  SIGNS  OF  EXTERNAL  ANEURYSM.       275 

Rupture  when  it  occurs  into  a  serous  cavity  is  generally  by  a  rent 
or  fissure ;  into  a  mucous  canal,  by  a  small  round  ulcerated  open- 
ing ;  on  to  a  cutaneous  surface,  by  sloughing  of  the  skin  covering 
the  sac.  In  the  first  case  the  rupture  is  generally  rapidly  fatal 
from  excessive  haemorrhage ;  in  the  last  two,  as  a  rule,  only  after 
repeated  haemorrhages,  the  slough  having  at  first  a  tendency  to 
cause  the  coagulation  of  the  blood  and  block  the  opening. 

P?-essure  effects. — The  pressure  of  the  sac  of  an  aneur}'^sm  may 
cause — I,  inflammation  and  condensation  of  the  parts  around, 
which  thus  become  blended  with  the  sac  ;  2,  diminution  or  ob- 
literation of  the  lumen  of  a  large  vein  ;  and  hence  3,  oedema  and 
dilatation  of  the  superficial  veins ;  4,  irritation  or  interruption  of 
the  conducting  power  of  nerves  giving  rise  to  pain,  spasm,  or 
paralysis  ;  5,  erosion  of  the  bones  and  cartilage ;  6,  obstruction 
of  the  oesophagus,  trachea,  or  thoracic  duct. 

Effects  on  the  circulation. — Hypertrophy  of  the  left  ventricle  of 
the  heart :  obstruction  of  vessels  and  enlargement  of  the  anasto- 
motic channels  ;  syncope,  and  gangrene. 

Symptoms  and  signs  of  external  aneurysm. — The  attention  is 
usually  first  drawn  to  the  disease  by  pain,  swelling,  and  a  feeling 
of  muscular  weakness,  or  by  stiffness  in  a  joint.  On  examination 
a  tumor  is  discovered  in  the  course  of  the  main  artery.  It  pul- 
sates, and  the  pulsation  is  expansile,  that  is,  on  placing  the  hand 
upon  the  aneurysm,  it  is  felt  at  each  systole  of  the  heart  to  enlarge 
in  every  direction,  or  if  the  hands  are  placed  on  either  side  of  the 
tumor,  they  are  seen  to  be  slightly  separated  at  each  pulsation. 
If  the  artery  on  the  cardiac  side  of  the  tumor  can  be  compressed, 
the  pulsation  of  the  tumor 

is    felt   to  cease,  and  the  Fig.  95. 

tumor  itself  to  become  per- 
ceptibly smaller  and  less 
tense.  On  cessation  of 
the  pressure,  however,  it 
quickly  fills  again  in  two 
or  three  forcible  pulsations, 

and      resumes      its      former        Sphygmosraphic  tracing  of  the  pulse  in  an  artery 

,  y^  •    •  1  below  an  aneurysm  f^B)  compared  with  that  of  the 

characters.      On  raising  the  pulse  on  the  sound  side  (a).     (After  Mahomed.) 

limb  the  pulsation  is  less 

forcible ;  on  lowering  the  hmb  more  forcible,  the  tumor  at  the 
same  time  becoming  more  tense.  The  pulse  below  the  tumor  is 
smaller  on  the  affected  than  on  the  sound  side,  and  a  sphygmo- 
graphic  tracing,  if  taken,  shows  the  pulse  is  delayed  on  the  dis- 
eased side  and  diminished  in  force,  the  tracing  being  less  abrupt 
in  its  rise  and  more  rounded  (Fig.  95,  b).  On  listening  with  the 
stethoscope,  a  bruit  is  heard  in  most  cases.     In  consequence  of 


276  DISEASES   OF   SPECIAL   TISSUES. 

pressure  on  the  vein  corresponding  to  the  artery,  there  is  often 
oedema  of  the  part  below,  and  sometimes  varicosity  of  the  super- 
ficial veins. 

In  internal  aneurysms,  no  tumor  may  be  felt ;  the  signs  are 
then  often  obscure,  and  the  diagnosis  will  depend  upon  the  effects 
the  aneurysm  produces  by  pressing  upon  important  parts.  Thus, 
in  thoracic  aneurysms,  there  may  be  pain,  dyspnoea,  dysphagia, 
cough,  aphonia,  dilatation  of  the  pupil  on  one  side,  enlargement 
of  the  superficial  veins,  and  oedema  of  one  arm  ;  signs  readily  ex- 
plainable by  the  pressure  on  the  nerves,  trachea,  bronchi, 
oesophagus,  and  arteries  and  veins  of  the  thorax.  But  for  a  more 
detailed  account  of  the  symptoms  of  internal  aneurysm,  a  work  on 
Medicine  must  be  consulted. 

The  signs  of  an  aiieurysm  undergoing  spontaneous  cure  are 
usually  obvious.  The  tumor  decreases  in  size,  and  the  pulsation 
in  it  gets  gradually  less  and  finally  ceases.  At  times  a  rapid  cure 
may  ensue ;  the  pulsation  then  ceases  suddenly,  and  the  tumor 
is  felt  to  be  hard,  the  patient  often  complaining  of  great  pain  at 
the  moment  of  consolidation. 

The  signs  of  a  leaking  aneuiysm,  i.  e.,  an  aneurysm  in  which 
blood  is  beginning  to  be  slowly  effused  into  the  tissues,  are  as 
follows  :  The  pulsation  is  less  distinct,  the  outline  of  the  tumor 
less  circumscribed,  the  growth  progressive,  and  the  pressure-signs 
are  more  urgent. 

The  signs  of  sudden  rupture  of  an  aneurysm. — i.  If  the  rupture 
is  into  a  serous  cavity,  the  signs  are  those  of  internal  haemorrhage, 
rapidly  followed  by  death.  2.  If  into  a  mucous  canal  there  will 
be  sudden  hremoptysis  in  the  case  of  the  trachea  or  bronchus, 
hsematemesis  in  the  case  of  the  oesophagus  or  stomach,  melrena, 
if  the  patient  lives  long  enough,  in  the  case  of  the  intestines.  3. 
If  the  blood  is  effused  into  the  tissues,  there  will  be  pain,  faint- 
ness,  loss  of  pulsation  and  bruit,  rapid  increase  in  the  size  of  the 
swelling,  oedema,  coldness,  and  cessation  of  the  pulse  in  the  parts 
below,  followed  by  increasing  syncope  from  loss  of  blood,  or  if 
death  does  not  soon  occur,  by  gangrene.  4.  Rupture  externally 
is  very  rare ;  the  signs  are  evident. 

Diagnosis. — An  aneurysm  may  have  to  be  diagnosed  from  sim- 
ple dilatation  of  an  artery,  an  abscess  or  tumor  over  an  artery,  a 
pulsatile  tumor  of  bone,  and  enlargement  of  the  thyroid  gland. 
In  a  simple  dilatation,  there  is  an  absence  of  bruit.  In  an  abscess 
or  tumor  over  an  artery,  the  pulsation  is  not  expansile,  there  is  no 
bruit,  and  the  swelling  is  not  emptied  or  made  less  tense  on  com- 
pressing the  artery  above.  A  tumor  can  often  be  lifted  from  the 
vessel.  In  the  case  of  an  abscess,  there  will  probal)ly  be  a  history 
or  signs  of  previous  inflammation.     In  a  tumor  raising  an  artery 


TREATMENT.  277 

over  if,  the  pulsation  is  only  felt  in  the  course  of  the  artery,  and 
there  is  no  expansile  pulsation  in  the  swelling.  In  pulsatile  tumor 
of  bone,  the  pulsation  is  not  equally  expansile  all  over;  and 
although  pulsation  is  stopped  on  compressing  the  artery  above, 
the  swelling  does  not  become  smaller  like  an  aneurysm,  or  refill 
on  removal  of  the  pressure  in  two  or  three  beats  of  the  heart. 
Portions  of  expanded  bone  may  also  be  felt  in  parts  of  the  tumor, 
and  there  may  be  glandular  enlargement  and  other  signs  of 
malignancy.  From  an  enlarged  thy )'o id  gland,  a  carotid  aneurysm 
may  be  distinguished  by  the  gland  moving  with  the  larynx  on 
deglutition. 

Treatment. — In  no  disease,  perhaps,  has  an  accurate  knowl- 
edge of  its  pathology  done  more  to  ensure  success  in  treatment 
than  in  aneurysm.  The  older  surgeons,  beheving  that  the  clot 
possessed  vicious  properties,  directed  their  efforts  to  the  empty- 
ing of  the  sac  ;  and  it  was  not  until  the  fact  became  fully  recog- 
nized that  nature's  method  of  curing  an  aneurysm  was  by  filling 
the  sac  with  organizable  clot,  that  the  lamentable  results  attend- 
ing the  treatment  of  aneurysm  in  olden  times  gave  place  to  the 
brilliant  successes  of  modern  surgery.  Our  treatment  at  the  pres- 
ent day  is  therefore  directed  rather  to  aiding  or  promoting  na- 
ture's efforts  than  to  thwarting  them.  Thus,  the  modern  surgeon, 
by  means  of  rest,  low  diet,  recumbency,  and  certain  medicines, 
endeavors  to  lessen  the  force  of  the  blood-current  through  the 
sac,  and  thus  to  aid  nature  in  the  deposition  of  laminated  fibrin. 
By  compression  or  hgature  of  the  artery  between  the  aneurysm 
and  the  heart  he  aims  at  diminishing  the  flow  of  blood  through 
the  artery  leading  to  the  aneurysm,  and  in  this  m.anner  seeks  a 
like  result.  By  manipulation  and  the  use  of  the  distal  ligature, 
he  endeavors  to  copy  the  method  of  spontaneous  cure  that  is 
sometimes  brought  about  by  the  plugging  of  the  artery  beyond 
the  aneurysm  ;  whilst  by  flexion,  he  imitates  nature's  method  of 
cure  by  the  pressure  of  the  aneurysm  itself  on  the  artery  either 
above  or  below  the  sac.  The  treatment  of  aneurysm,  therefore, 
may  be  divided  into  the  medical  or  general,  and  the  surgical  or 
local. 

Medical  treatment. — Both  internal  and  external  aneurysms  have 
been  cured  by  medical  treatment  alone.  Indeed,  in  some  forms 
of  internal  aneurysm,  it  is  the  only  means  at  our  command.  In 
external  aneurysms,  however,  local  treatment  in  addition  is  nearly 
always  expedient  or  necessary.  Absolute  rest,  both  bodily  and 
mental,  should  be  enjoined  ;  the  patient  must  lie  in  bed,  and 
must  not  move  for  any  purpose  whatever,  not  even  to  feed  him- 
self. The  diet  should  be  limited  in  quantity,  unstimulating  but 
nutritious  in  quality,  and  the  fluid  portion  restricted  as  much  as 


278  DISEASES   OF   SPECIAL  TISSUES. 

possible.  The  following  diet  scale  is  advised  by  Mr.  Jolliffe 
Tufnell :  Bread  and  butter,  4  ozs. ;  meat,  3  ozs. ;  potatoes,  3  ozs. ; 
fluid,  8  ozs.  in  the  twenty-four  hours.  Small  repeated  bleedings, 
where  there  is  excessive  action  of  the  heart,  or  the  patient  is 
plethoric,  may  occasionally  be  useful.  Medicines  seem  to  have 
little  efficacy,  but  iodide  of  potassium  in  large  doses,  acetate  of 
lead,  aconite,  and  digitalis  have  been  recommended,  either  for 
promoting  the  coagulation  of  the  blood,  or  retarding  the  heart's 
action.  Where  there  is  a  history  of  syphilis,  iodide  of  potassium 
should  certainly  be  given 

Surgical  treatment. — In  all  suitable  cases  of  external  aneurysm, 
pressure,  when  it  can  be  applied  between  the  aneurysm  and  the 
heart,  should  first  be  tried,  aided  under  certain  circumstances  by 
the  method  of  flexion.  But  these  failing,  or  appearing  unsuitable, 
the  artery  should  be  tied,  if  practicable,  on  the  proximal  side,  and 
preferably  at  some  distance  from  the  sac  where  the  artery  is  more 
likely  to  be  healthy.  Where  pressure  or  ligature  cannot  be  used 
on  the  proximal  side,  as  for  instance,  in  aneurysms  at  the  root  of 
the  neck,  it  becomes  a  question  whether  we  should  try  distal 
pressure  or  ligature,  scratching  the  wall  with  needles  (^Maceweti' s 
method),  manipulation,  galvano-puncture,  coagulating  injections, 
or  the  introduction  of  wire  or  horsehair;  or  fall  back  on  medical 
means  alone.  In  some  varieties  of  traumatic  aneurysm  where  the 
artery  is  presumably  healthy,  and  in  certain  forms  of  aneurysm, 
as  gluteal,  where  a  ligature  of  the  artery  at  a  distance  from  the 
sac  is  attended  with  excessive  risk,  it  may  even  be  expedient  to 
resort  to  the  old  method  of  opening  the  sac,  turning  out  the  clot, 
and  securing  both  ends  of  the  bleeding  vessel  by  ligature.  Each 
of  these  methods  requires  discussion.  Before  resorting  to  surgi- 
cal methods,  however,  the  circulation  through  the  aneurysm  should 
have  been  previously  quieted  as  much  as  possible  by  rest,  recum- 
bency, restriction  of  the  diet,  and  regulation  of  the  secretions. 
Where  the  aneurysm  is  on  an  artery  of  the  lower  extremity,  any 
embarrassment  of  the  venous  circulation  and  consequent  oedema 
that  may  be  present,  should  be  lessened  or  removed  by  elevating 
and  lightly  bandaging  the  limb. 

Prkssukk, — This  method  of  treating  aneurysm  was  known  to 
the  older  Surgeons,  but  in  consequence  of  their  efforts  being 
directed  either  to  the  emptying  of  the  sac  by  direct  pressure  upon 
it,  or  to  the  obliteration  of  the  artery  leading  to  it  by  adhesive 
inllammation,  it  was  attended  with  such  unfavorable  results  that 
it  fell  into  disuse.  To  the  Dublin  Surgeons,  who  recognized  the 
fact  that  it  was  not  necessary  to  obliterate  the  artery  in  order  to 
cause  consolidation  of  the  aneurysm,  is  due  in  chief  part  the  credit 
of  reviving  treatment  by  pressure.    The  object  of  pressure  as  now 


PRESSURE.  279 

employed,  is  to  produce  consolidation  of  the  aneurysm  by  the 
formation  of  either  a  laminated  or  an  ordinarj-  coagulum.  The 
methods  of  bringing  this  about  maybe  considered  under  i,  direct 
pressure  on  the  aneurysm ;  and  2,  indirect  pressure,  either  on  the 
artery  above,  on  the  artery  below,  or  on  both  simultaneously. 

1.  Direct  pressure  is  now  seldom  used,  exxept  in  as  far  as  flex- 
ion may  be  considered  as  in  part  a  method  of  direct  pressure, 
although  several  successful  cases  have  of  late  been  reported.  It 
will  not  receive  further  notice. 

2.  Indirect  pressure,  whether  applied  to  the  artery  above,  the 
artery  below,  or  to  both  at  the  same  time,  may  be  considered 
under  the  heads  of —  {a)  Digital  pressure.  {d)  Instrumental 
pressure,  {c)  Pressure  by  Esmarch's  bandage,  {d)  Pressure 
by  flexion  of  the  limb. 

{a)  Digital  pressure,  where  it  can  be  applied  to  the  artery  on 
the  proximal  side  at  some  distance  from  the  sac,  is  undoubtedly 
the  safest  and  probably  best  method  of  treating  an  aneurysm  ;  and 
it  is  the  one,  other  things  being  favorable,  which  should  usually 
first  be  tried.  There  are  some  Surgeons,  however,  who,  now  that 
the  healing  of  the  wound  for  the  ligature  of  an  artery  can  practi- 
cally be  assured  by  the  first  intention,  prefer  ligature  to  pressure 
as  the  more  certain  though  perhaps  the  more  risky  method.  The 
advantages  claimed  for  digital  pressure  are — i,  that  it  causes  less 
pain  than  other  forms  of  pressure  \  2,  that  the  artery  can  be  com- 
pressed with  little  or  no  interference  with  the  venous  circulation ; 
3,  that  it  is  less  liable  to  injure  the  tissues  ;  and  4,  that  in  com- 
mon with  other  methods  of  pressure,  it  does  not  expose  the 
patient  to  the  dangers  of  an  open  wound.  Pressure  treatment 
requires  a  relay  of  intelligent  assistants,  acting  in  pairs  and  alter- 
nately compressing  the  artery  for  about  ten  minutes  at  a  time. 
Whilst  one  presses  the  artery,  the  other  should  have  his  hand  on 
the  aneurysm,  to  ascertain  if  pulsation  is  being  properly  controlled. 
The  fingers  of  the  one  assistant  should  not  be  removed  till  the 
other  has  taken  his  place,  as  the  artery  must  on  no  account  escape 
compression  for  a  single  moment.  The  pressure  of  the  fingers 
may  be  aided  by  a  shot-bag,  and  the  spot  at  which  pressure  is 
appUed  may  be  slightly  varied  from  time  to  time.  Opinions  dif- 
fer as  to  whether  the  circulation  should  be  completely,  or  only 
partially,  stopped  through  the  artery,  and  whether  the  pressure 
should  be  continued  both  day  and  night,  or  only  during  the  day. 
Aneurysms  have  been  cured  by  digital  pressure  in  a  few  hours, 
but  some  days  are  usually  necessary  ;  and  to  obtain  success,  much 
care  and  attention  to  detail  is  required. 

{b)  Instrumental  pressure  may  be  appHed  so  as  only  partially 
to  control  the  circulation  through  the  artery,  and  thus  induce  the 


28o 


DISEASES   OF   SPECIAL   TISSUES. 


gradual  obliteration  of  the  aneurysm  by  the  deposit  of  laminated 
fibrin  in  the  sac  {s/ow  pressiire)  ;  or  it  may  be  applied  so  as  to 
completely  control  the  flow  of  blood  through  the  vessel,  and  in- 
duce rapid  coagulation  in  the  sac  {rapid  pj-essto-e).  The  latter 
method  can  only  be  done  under  an  anaesthetic,  but  has  been  at- 
tended with  some  brilliant  results,  especially  in  cases  of  abdom- 
inal aneurysm.  As  a  rule  for  external  aneurysms,  however,  the 
milder  measures  will  suffice,  and  it  is  a  question  if  these  fail 
whether  it  is  not  better  treatment  to  ligature  the  artery  than  sub- 
ject the  patient  to  further  attempts  at  cure  by  rapid  pressure. 
Both  kinds  of  pressure  may  be  applied  by  one  or  other  of  the 
many  forms  of  compressors  and  tourniquets  which  have  been  in- 
vented for  the  purpose  (Figs.  96,  97,  and  98).  It  is  better  when 
possible  to  apply  the  pressure  to  one  artery,  though  slightly  vary- 
ing its  position,  than  to   change  from  one   artery  to  another,  as 


Fig.  96. 


Fig.  97. 


Fig.  98. 


De  Carte's  Tourniquet.        Lister's  Abdominal  Tourniquet. 


Skey's  Tourniquet. 


from  the  superficial  to  the  common  femoral,  since  by  so  doing 
different  sets  of  anastomosing  arteries  are  enlarged,  and  the  col- 
lateral circulation  may  become  too  free. 

Cases  U7isititable  for  pressure. — i.  Where  the  aneurysm  is  of 
very  large  size,  or  is  rapidly  increasing.  2.  Where  the  sac  is  thin, 
contains  but  little  fibrin,  and  appears  likely  soon  to  burst.  3. 
Where  there  is  much  oedema  from  venous  obstruction.  4.  Where 
the  patient  is  of  an  irritable  disposition,  is  intolerant  of  pain,  or 
has  been  addicted  to  the  abuse  of  alcohol.  It  is  considered  by  some 
that  even  if  pressure  fails,  good  may  have  been  done  by  causing  a 
deposit  of  fibrin  in  the  sac,  and  by  enlarging  the  collateral  vessels. 
By  others  these  advantages  are  thought  to  be  outweighed  by  the 
irritation  and  disappointment  to  the  patient  of  failure,  and  the 
bruising  and  injury  of  the  tissues  at  the  situation  where  the  artery 
will  have  to  be  tied. 


LIGATURE.  281 

(r)  Pressure  by  Esmarch''s  bandage  {Reid^s  method)  aims  at 
simultaneously  compressing  the  artery  above  and  below  the 
aneurysm,  and  thus  causing  the  blood  contained  in  both  the 
aneurysm  and  the  artery  to  coagulate.  The  elastic  bandage,  in 
the  case  of  popliteal  aneurysm,  in  which  this  method  of  compres- 
sion has  most  often  been  used,  should  be  evenly  applied  from  the 
foot  as  far  as  the  aneurysm  ;  a  turn  should  be  then  made  over  the 
tumor,  so  as  only  lightly,  if  at  all,  to  compress  the  sac,  and  the 
bandaging  then  continued  firmly  half  way  up  the  thigh.  The 
bandage  should  be  kept  on  for  an  hour  to  an  hour  and  a  half. 
The  elastic  cord  should  not  be  used  at  all.  On  removing  the 
bandage  digital  pressure  should  be  kept  up  on  the  main  artery 
from  thirty-six  to  forty-eight  hours,  so  as  to  control  the  circula- 
tion and  prevent  the  clot,  while  still  soft,  from  being  washed  out 
of  the  artery  and  sac.  The  patient  must  be  placed  under  an 
anaesthetic  during  the  use  of  the  bandage,  as  it  causes  great  pain. 
Many  cases  have  been  cured  by  this  method ;  but  on  the  other 
hand  there  have  been  many  failures,  and  it  is  far  from  being  un- 
attended with  danger.  Thus,  gangrene  of  the  limb  and  rupture 
of  the  sac  have  ensued,  and  aneurysms  of  internal  arteries  have 
been  produced  apparently  by  the  prolonged  increase  of  blood- 
pressure  in  the  rest  of  the  arterial  system. 

{d)  Pressure  by  Flexion  {Harfs  melhod)  consists  in  flexing 
the  limb  so  as  to  compress  the  artery  by  the  aneurysm,  in  imita- 
tion of  that  form  of  spontaneous  cure  which  is  brought  about  by 
the  pressure  of  the  aneurysm  itself  on  the  artery  above  and  below. 
It  is  obviously  applicable  to  aneurysms  in  but  very  few  situations, 
and  has  been  most  successful  in  those  of  the  popliteal  artery.  It 
may  be  used  either  alone,  or  in  conjunction  with  digital  or  other 
pressure,  or  with  medical  treatment.  This  treatment  causes  much 
pain,  and  can  seldom  be  endured. 

Ligature,  like  pressure,  is  a  very  old  method  of  treatment,  but 
to  Anel  and  John  Hunter  is  due  the  credit  of  havmg  placed  it  on 
a  scientific  basis.  The  older  surgeons  laid  open  the  sac  and 
turned  out  the  clots,  and  endeavored  to  staunch  the  hsemorrhage 
by  ligaturing  the  artery  above  and  below  the  aneurysm.  Antyllus, 
it  is  true,  applied  his  ligatures  before  opening  the  sac ;  but  it 
was  not  until  centuries  afterwards  that  Anel  recognized  the  fact 
that  it  was  unnecessary  to  open  the  sac  at  all,  and  tied  the  artery 
immediately  above  the  aneurysm.  Many  years  later  Hunter  per- 
ceived that  the  more  or  less  complete  stoppage  of  the  circulation 
obtained  by  Anel's  method  was  not  necessary,  and  that  the  liga- 
ture of  the  artery  close  to  the  sac  was  attended  with  the  risk  of 
secondary  haemorrhage  and  inflammation  of  the  sac.  He,  there- 
fore, applied  his  ligature  at  a  distance  from  the  aneurysm,  wheie 

13* 


DISEASES   OF   SPECIAL   TISSUES. 


Fig.  gg. 


Different  positions  of  ligature  for  aneur- 
ysm. 

A.  Antyllus's  method;  B.  Anel's;  c- 
Hunter's;  d.  Brasdor's;  and  e.  War- 
drop's. 


he  had  observed  moreover  that  the  artery  was  likely  to  be  in  a 
healthier  condition.  For  aneurysms  so  situated  that  a  ligature 
cannot  be  placed  on  the  cardiac  side,  Brasdor  proposed  tying  the 

trunk  of  the  artery  on  the  distal 
side  of  the  aneurysm  ;  whilst  War- 
drop  suggested  tying  one  or  two 
of  the  terminal  branches  of  the 
artery  on  the  distal  side  of  the 
aneurysm,  where  neither  Brasdor's 
/\  17  I  r  f  \  {  ]  operation  nor  the  proximal  liga- 
(  )  Pv  (  ]  \  J  [J  ture  was  applicable.  Hence  liga- 
ture for  aneurysm  may  be  apphed 
(Fig.  99),  1.  On  the  proximal 
SIDE  of  the  aneurysm  either  at  a 
distance  {Hunter's  method),  or 
immediately  above  it  {Anel's 
method).  2.  On  THE  distal  side 
of  the  aneurysm,  either  to  the 
main  trunk  {Brasdof''s  method), 
or  to  one  or  more  of  the  main  branches  {Wardrop's  method). 
3.  Immediately  above  and  below  the  aneurysm,  either  opening 
the  sac  {the  old  operation),  or  without  opening  the  sac  {Antyllits' 
method). 

I.  The  proximal  ligature.  A.  Hunter's  method. — This  ope- 
ration, when  applicable,  is  the  one  now  almost  universally  adopted. 
The  chief  merits  claimed  for  it  are — i.  That  the  artery  at  the 
spot  selected  for  hgature  is  not  only  more  likely  to  be  healthy,  but 
is  also  more  easily  tied  than  the  artery  in  close  proximity  to  the 
sac,  in  which  latter  situation,  moreover,  its  anatomical  relations 
are  liable  to  be  disturbed  by  the  aneurysm.  2.  That  the  sac  is 
not  interfered  with,  and  hence  is  less  likely  to  become  inflamed 
and  suppurate ;  and  3.  That  as  several  branches  will  probably  be 
given  off  between  the  ligature  and  the  aneurysm,  the  circulation 
through  the  sac,  though  lessened,  will  not  be  completely  arrested, 
and  the  clot  is  therefore  more  likely  to  have  a  laminated,  and 
hence  a  permanent  character. 

Effects  of  the  proximal  liffatnre. — After  the  successful  ap])lica- 
tion  of  a  ligature  by  the  Hunterian  method,  the  ]julsation  in  the 
aneurysm  immediately  ceases,  and  for  a  time  the  circulation 
through  the  limb  is  diminished.  Hence  the  temperature  becomes 
lower  and  the  surface  pale.  Soon,  however,  the  collateral  circula- 
tion becomes  established,  and  a  faint  pulsation  may  be  felt  again 
in  the  aneurysm  ;  but  this  recurrent  pulsation  usually  grows  less 
from  day  to  day,  and  shortly  ceases,  and  the  aneurysm  slowly 
shrinks   and  is  finally   absorbed,  or   remains  as   a  small,    hard, 


THE    DANGERS    OF    LIGATURE. 


283 


Fig.  10:1. 


I 


fibrous  mass.  The  artery  leading  to  the  aneur}'Sm  may  remain 
pervious,  but  it  more  frequently  becomes  obliterated  as  far  as 
the  first  collateral  branch  above  and  below  the  sac.  The  artery 
on  either  side  of  the  ligature  also  becomes  ob- 
literated as  far  as  the  first  collateral  branch. 
This  condition  of  an  aneurysm  and  artery  after 
ligature  is  seen  in  the  accompanying  diagram 
(Fig.  100).  The  blood  passes  the  ligature  by  the 
collateral  channels  ;  re-enters  the  artery  below  ; 
passes  the  obstruction  where  the  artery  is  closed 
at  the  seat  of  the  aneurysm,  also  by  collateral 
channels ;  and  then  again  enters  the  main  artery. 

Treatment  afte)'  ligature. — The  limb  should  be 
completely  swathed  in  the  cotton- wool  and  flannel 
bandages  (which,  before  the  operation,  should 
have  already  been  carried  up  as  far  as  the  seat 
of  the  ligature),  and  kept  at  perfect  rest.  In 
the  case  of  popliteal  aneurysm,  the  limb  should 
be  slightly  raised  on  a  pillow,  and  placed  on  its 
outer  side,  with  the  knee  a  little  flexed,  care 
being  taken  that  no  pressure  is  made  on  the  heel, 
malleoli,  or  other  points  of  bone,  for  fear  of  local 
sloughing.  If  the  weather  is  at  all  cold,  hot 
bottles  should  be  appUed,  near,  but  not  in  con- 
tact with,  the  limb.  The  patient  must  be  kept  in 
bed  till  the  aneurysm  is  thoroughly  consolidated, 
and  the  operation  wound  has  healed. 

The  dangers  of  ligature. — These  are — {ji) 
secondary  haemorrhage  ;  (^)  gangrene  ;  (^)  re- 
current pulsation ;  {d)  suppuration  and  slough- 
ing of  the  sac  ;  {e)  phlebitis;  (/)  great  enlarge- 
ment of  the  aneurs'sm  without  pulsation  ;  and 
{g)  the  other  dangers  that  may  attend  any  open 
wound . 

(^)  Secondary  hce??ior?-hage  is  liable  to  occur  at  any  period  be- 
fore the  wound  is  soundly  healed.  The  causes,  symptoms,  and 
treatment,  are  discussed  under  "Haemorrhage,"  see  p.  134. 

{[>)  Gangrene  \5  more  common  in  the  leg  than  in  the  arm; 
indeed,  in  the  latter  situation  it  is  very  rare.  It  may  be  due  to — 
I,  failure  of  establishment  of  the  collateral  circulation,  when  it 
usually  supervenes  within  a  few  days ;  or  2,  venous  obstruction, 
the  result  of  plugging  of  the  vein  in  consequence  either  of  injury 
at  the  time  of  operation,  or  of  pressure  on  the  vein  by  a  swollen 
and  suppurating  sac.  When  due  to  the  latter  conditions,  it  may 
be  delayed  for  some  weeks.     When  extensive  and  spreading  rap- 


ii 


Diagram  to  show  the 
condition  of  the 
arterj'  and  aneu- 
rysm after  the 
Hunterian  liga- 
ture, and  the  es- 
tablishment of  the 
collateral  circula- 
tion. The  arrows 
indicate  the  direc- 
tion of  the  blood 
current. 


284  DISEASES   OF   SPECUL   TISSUES. 

idly,  amputation  at  the  seat  of  ligature  must  be  performed.  The 
Surgeon,  however,  should  not  be  in  too  much  haste  to  amputate, 
as  the  gangrene  may  involve  only  a  toe  or  two,  or  part  of  the  foot, 
and  spread  no  further.  When,  therefore,  it  is  limited  in  extent, 
and  spreading  slowly,  a  line  of  demarcation  should  be  waited  for 
before  amputation  is  performed.  When  the  sac  is  very  large,  and 
the  gangrene  appears  to  be  due  to  pressure  on  the  vein,  the  sac 
may  at  times  be  opened  with  advantage,  the  clots  turned  out,  and 
any  bleeding  vessels  secured. 

{c)  Recurrent  pulsation,  when  slight,  is  a  good  sign,  as  it  shows 
that  the  collateral  circulation  is  becoming  established,  and  conse- 
quently that  the  danger  of  gangrene  is  lessened,  if  not  passed. 
If,  however,  instead  of  ceasing,  as  it  usually  does  in  a  few  days,  it 
becomes  more  pronounced,  the  hmb  should  be  raised,  and  care- 
fully bandaged  from  the  foot  upwards,  and  pressure  applied  to  the 
artery  leading  to  the  sac.  If  this  does  not  suffice,  and  the  pulsa- 
tion returns  as  strongly  as  ever,  and  the  aneurysm  again  begins  to 
increase  in  size,  it  is  clear  that  the  ligature  has  failed  ;  and  it  be- 
comes a  grave  question  what  further  treatment  should  be  under- 
taken. Should  it  appear  that  a  large  branch  is  feeding  the 
aneurysm,  this  should  undoubtedly  be  secured  ;  otherwise  the 
choice  will  probably  lie  between — i,  pressure  upon  the  artery  and 
aneurysm ;  2,  the  use  of  Esmarch's  bandage  ;  3,  flexion  in  the 
case  of  a  popliteal  aneurysm  ;  or  if  these  fail,  4,  tying  the  vessel 
either  just  above  the  aneurysm,  or  above  the  former  ligature;  5, 
cutting  down  upon  the  sac,  and  securing  both  ends  of  the  artery ; 
or  6,  amputation.  Much  will  turn  on  each  individual  case,  but 
the  discussion  as  to  a  choice  of  method  is  too  long  to  be  entered 
upon  here. 

{d)  Inflanunation  and  suppuration  of  the  sac  may  be  met  with 
after  pressure,  as  well  as  after  ligature ;  and  although  it  may  occur 
after  the  Hunterian  operation,  is  more  frequent  in  cases  where 
the  ligature  has  been  applied  close  to  the  sac,  or  where  rapid 
pressure  has  been  used.  It  appears  to  be  due  to — i,  the  spread 
of  inflammation  to  the  sac  from  the  wound  ;  2,  the  formation  in 
the  sac  of  a  soft  coagulum  ;  or  3,  excessive  manipulation  before 
the  operation.  It  is  ushered  in  with  redness,  heat,  pain,  and 
swelling  of  the  sac  (which  has  not  undergone  the  usual  process 
of  shrinking),,  and  oedema  of  the  surrounding  parts.  Later  the 
skin  gives  way  and  a  mixture  of  jjus  and  broken-down  coagula 
escapes.  It  may  be  accompanied  l)y  haemorrhage ;  but  more 
commonly  the  vessel  has  become  sealed  and  no  bleeding  occurs. 
The  abscess  should  be  opened  as  soon  as  pus  has  formed,  a 
grooved  needle  being  previously  inserted  if  there  is  doubt  on  this 
point.     Should  haemorrhage  occur,  the  clots  must  be  turned  out, 


THE    DISTAL    LIGATURE,  285 

and  the  artery  secured  above  and  below,  or  amputation  per- 
formed. 

((?)  Phlebitis  may  occur  from  injury  to  the  vein  in  passing  the 
aneurysm  needle.  Should  the  vein  be  pricked,  an  accident 
which  may  be  known  by  venous  blood  welling  up  by  the  side  of 
the  ligature,  the  artery  should  on  no  account  be  tied  at  this  spot, 
as  the  ligature  would  act  as  a  seton  in  the  vein,  and  death  possi- 
bly ensue  from  phlebitis  or  pyaemia.  The  ligature,  if  already 
passed,  should  be  withdrawn,  pressure  applied  to  the  vein,  and 
the  artery  tied  higher  up.  Where  this  treatment  has  been 
adopted  I  have  never  seen  any  ill  results  follow  the  injury. 

B.  Anei.'s  operation  is  seldom  done  except  where  the  Hun- 
terian  method  is  inapplicable,  as  for  aneurysm  in  the  groin, 
aneurysm  of  the  upper  part  of  the  common  carotid,  etc.  The 
disadvantages  said  to  attend  it  are — i,  that  the  artery  is  likely  to 
be  diseased,  and  hence  there  is  greater  risk  of  secondary  hsemor- 
rhage  ;  2,  that  its  anatomical  relations  are  apt  to  be  disturbed 
by  the  contiguity  of  the  sac  ;  3,  that  the  sac  itself  is  liable  to  be 
injured  during  the  operation,  and  to  become  inflamed  and  sup- 
purate ;  and  4,  that  the  clot  which  forms  in  the  sac  is  of  the  soft 
or  passive  variety  in  consequence  of  there  being  no  circulation  in 
the  sac.  Recently  this  method  has  been  revived  at  St.  Bartholo- 
mew's for  the  treatment  of  popliteal  aneurysm,  and  the  popliteal 
artery  is  there  now  frequently  tied.  It  has  been  found  to  di- 
minish the  risk  of  gangrene,  and  holds  out  a  greater  certainty  of 
cure.  Gangrene  is  less  likely  to  occur  when  only  the  popliteal  is 
obstructed  close  to  the  aneurysm  than  when  both  the  popliteal  and 
femoral  are  blocked.  Recurrent  pulsation  and  failure  after  liga- 
ture of  the  femoral  are  due  to  too  free  a  supply  of  blood  flowing 
into  the  artery  below  the  ligature  (Figs.  100,  104)  ;  when  the 
popliteal  is  tied  this  is  prevented.  Moreover  the  poptiteal  has 
been  found  quite  as  healthy  as  the  femoral ;  it  is  easily  tied  at  its 
upper  part  without  disturbing  the  sac  ;  and  there  appear  to  be 
sufficient  small  vessels  given  off  from  the  artery  between  the  liga- 
ture and  the  aneurysm  to  ensure  by  their  anastomosis  with  other 
small  vessels  given  off  above  the  ligature  some  circulation  in  the 
sac  and  the  formation  of  an  active  clot. 

2.  The  distal  ligature  should-  only  be  used  where  the  Hun- 
terian  or  Anel's  method  cannot  be  apphed.  Brasdor's  method, 
which  consists  in  securing  the  main  trunk  on  the  distal  side  of 
the  aneurysm,  may  be  employed  in  aneurysm  of  the  carotid  at  the 
root  of  the  neck.  It  copies  that  method  of  spontaneous  cure  in 
which  a  clot  blocks  the  artery  beyond  the  aneurysm.  After  the 
ligature  the  clot  that  forms  in  the  artery  may  extend  to  the 
aneurysm,  which  thus  becomes  filled  by  a  coagulum  ;  or  the  blood 


2  86  DISEASES    OF   SPECIAL   TISSUES. 

pressure  in  the  sac  may  become  so  diminished  that  laminated 
fibrin  is  deposited.  Unfortunately,  however,  in  practice  the 
blood-pressure  in  the  aneurysm  appears  in  some  cases  to  be  in- 
creased rather  than  diminished.  Wardrofs  method  consists  in 
securing  two  or  more  of  the  main  branches  of  the  artery  on  the 
distal  side  of  the  aneurysm.  It  aims  at  cutting  off  part  of  the 
blood-stream  through  the  aneurysm,  and  so,  by  reducing  the 
blood-pressure,  promoting  the  deposition  of  laminated  coagulum. 
It  has  been  applied  to  the  subclavian  and  carotid  arteries  for 
aneurysm  of  the  innominate  ;  but  the  success  attending  it  has  not 
been  great.  The  chief  risks  are  passive  enlargement  and  subse- 
quent bursting  of  the  sac,  or  inflammation  and  suppuration  of  the 
sac. 

3.  The  double  ligature. — Ligature  above  and  below  the  sac, 
either,  i,  by  the  old  method  of  first  laying  the  sac  open  and  then 
securing  the  bleeding  ends  of  the  artery ;  or,  2,  by  the  method  of 
Antyllus,  of  first  securing  the  artery  and  then  laying  the  sac  open, 
is  only  employed  in  exceptional'  cases.  Thus  the  old  method  is 
sometimes  resorted  to  in  traumatic  aneurysm  of  the  axillary 
artery  in  preference  to  tying  the  subclavian,  and  also  in  gluteal 
aneurysm  where  the  Hunterian  method  of  tying  the  common  or 
internal  iliac  is  attended  with  so  much  risk.  The  great  danger  is 
the  patient  dying  under  the  operation,  of  haemorrhage.  During 
the  operation,  therefore,  in  the  case  of  the  axillary  artery,  pres- 
sure should  be  made  on  the  subclavian,  an  incision  through  the 
skin  and  fascia  above  the  clavicle  being  made  to  ensure  its  better 
control.  In  the  case  of  the  gluteal,  Davy's  lever  or  the  abdom- 
inal tourniquet  should  be  used.  The  true  method  of  Antyllus 
may,  in  rare  instances,  be  required,  as  in  some  forms  of  aneurysm 
at  the  bend  of  the  elbow. 

Manipulation.  A  spontaneous  cure,  as  we  have  seen  (p.  274), 
is  sometimes  brought  about  by  the  impaction  of  a  portion  of  clot 
either  in  the  mouth  of  the  sac  or  in  the  artery  below.  Manipula- 
tion of  the  sac  aims  at  breaking  up  and  displacing  such  clot  as 
may  have  formed  in  the  hope  that  a  portion  may  become  im- 
pacted in  this  way,  and  so  lead  to  consolidation.  Sir  William 
Fergusson,  who  first  introduced  this  method,  used  it  with  success, 
and  others  have  done  so  likewise.  It  is  far  from  being  unat- 
tended with  danger,  however,  since  a  portion  of  the  clot  may  be 
carried  away  by  the  blood-stream  and  become  lodged  in  a  vessel 
leading  to  an  important  organ,  as  the  brain.  It  should,  there- 
fore, only  be  tried  when  other  means  are  impracticable  or  appear 
attended  with  even  greater  risk. 

Irritation  of  thk  interior  of  the  sac  by  needles  (Mac- 
ewen's  method).     This  method  aims  at  so  irritating  the  walls  of 


ANEURYSM  AT  THE  ROOT  OF  THE  XECK.  287 

the  aneurysm  as  to  induce  slight  inflammation  and  the  formation 
of  white  thrombus.  The  skin  having  been  made  aseptic,  long 
needles  are  passed  into  the  sac  and  the  walls  systematically 
scratched  all  around  the  aneurysm.  It  is  applicable  to  aneurysms 
where  pressure  or  proximal  hgature  cannot  be  employed.  Con- 
solidation occurs  very  slowly.  Our  experience  of  this  method  is 
at  present  ven,-  hmited.  In  a  case  of  aneurysm  at  the  root  of  the 
neck  in  which  I  tried  it,  the  results  were  such  as  to  lead  me  to 
think  it  has  a  future. 

GaLV.^^O-PUXCTURE,    ELECTROLYSIS,    IXJECIIOXS    OP     PERCHLORIDE 

OF  IRON,  tanxix,  and  the  like,  and  the  ixtroductiox  of  foreign 
BODIES  as  horsehair  or  irox  wire,  which  have  all  for  their  object 
the  coagulation  of  the  blood  in  the  sac,  are  highly  dangerous 
procedures,  and  have  not  hitherto  been  attended  with  much  suc- 
cess. 

SPECIAL  AXELTRYSMS. 

IxTERXAL  AXEURYSMS,  falling  as  they  do  under  the  care  of  the 
Physician  rather  than  of  the  Surgeon,  will  be  referred  to  only  in 
so  far  as  an  aneurysm  of  the  arch  of  the  aorta,  of  the  innominate, 
of  the  first  portion  of  the  subclavian,  and  of  the  portion  of  the 
left  common  carotid  within  the  chest,  may  present  as  a  pulsating 
tumor  at  the  root  of  the  neck,  and  as  such  may  call  for  surgical 
treatment. 

Aneurysm  at  the  root  of  the  neck. — The  differential  diag- 
nosis of  aneurysm  in  this  situation  is  always  difficult,  at  times  im- 
possible. Indeed  the  aneurysm  may  involve  inore  than  one 
artery,  perhaps  all  three  of  the  main  branches  of  the  aortic  arch, 
and  even  the  arch  itself  as  well.  The  sign  common  to  all  forms, 
whatever  the  artery  implicated,  is  a  pulsating  tumor  at  the  root  of 
the  neck,  in  which  a  loud  bruit  can  generally  be  heard.  When 
the  aneurysm  involves  the  aorta,  it  generally  presents  just  above 
the  suprasternal  notch,  and  there  are  symptoms  within  the  chest 
of  the  aorta  being  affected.  When  the  innominate  is  implicated, 
the  aneurysm  projects  between  the  two  heads  of  origin  of  the 
sterno-mastoid  muscle  ;  and  the  pulse  in  the  temporal  and  radial 
arteries  is  smaller  on  the  right  than  on  the  left  side,  and  is  aneur- 
ysmal in  character.  (See  p.  275.)  When  the  aneurysm  involves 
the  common  carotid,  it  presents  beneath  the  inner  head  of  the 
sterno-mastoid,  and  tends  to  extend  upward  in  the  neck  by  the 
side  of  the  trachea  ;  the  bruit  is  transmitted  up  the  carotid,  and 
the  pulse  in  the  temporal  is  smaller  on  the  affected  than  on  the 
sound  side  and  is  aneurysmal  :  but  the  pulse  in  the  radial  is  the 
same  on  both  sides.  When  the  subclavian  is  involved  the  tumor 
is  external  to  the  sterno-mastoid ;  it  extends  in  the  direction  .of 


288  DISEASES   OF   SPECLA.L   TISSUES. 

the  subclavian  artery ;  the  bruit  is  transmitted  towards  the  axilla  ; 
and  the  pulse  at  the  wrist  is  diminished  in  volume  and  is  aneur- 
ysmal. Such  is  a  brief  outhne  of  the  differential  diagnosis  of 
these  aneurysms  ;  but  there  are  many  other  signs  due  to  the  pres- 
sure of  the  aneurysm  on  the  veins,  nerves,  oesophagus,  trachea, 
etc.,  which  have  to  be  taken  into  consideration,  and  for  an  ac- 
count of  which  a  work  on  Medicine  must  be  consulted.  Treat- 
menf. — When  the  aneurysm  is  aortic  medical  means  alone  must 
be  relied  on.  When  the  innominate  is  involved,  Macewen's 
method  of  scratching  the  interior  of  the  sac  with  needles  should 
certainly  first  be  tried.  This  faihng,  medical  means  and  pressure 
on  the  carotid,  or  distal  hgature  of  the  carotid  and  subclavian 
arteries  simultaneously  may  be  employed.  If  these  do  not  prove 
successful,  or  are  impracticable  owing  to  the  large  size  of  the 
aneurysm,  nothing  is  left  but  the  desperate  resort  to  galvano- 
puncture,  electrolysis,  or  the  introduction  of  iron  wire.  When 
the  carotid  or  subclavian  is  affected,  Macewen's  method  and 
medical  means  may  also  in  the  first  instance  have  due  trial ; 
afterwards,  in  the  case  of  the  carotid,  distal  compression  or  liga- 
ture may  be  tried  ;  and  in  the  case  of  the  subclavian,  distal  com- 
pression or  ligature  if  practicable,  direct  pressure  on  the  sac,  or 
the  terrible  expedients  of  amputation  at  the  shoulder-joint,  liga- 
ture of  the  innominate,  manipulation,  galvano-puncture,  injection 
of  coagulants,  or  the  introduction  of  iron  wire. 

Carotid  aneurysiM. — Aneurysm  of  the  carotid  at  the  root  of 
the  neck  has  been  alluded  to  above.  Aneurysm  of  the  common 
trunk  higher  in  the  neck  presents  the  ordinary  signs  of  aneurysm, 
and  in  this  situation  has  to  be  diagnosed  from — i,  simple  dilata- 
tion of  the  artery  at  its  bifurcation;  2,  enlarged  glands;  3,  ab- 
scess or  tumor  over  the  artery;  4,  pulsating  goitre.  In  simple 
dilatation  there  is  no  bruit ;  in  enlarged  glands  and  tumors  there 
is  also  no  bruit,  and  the  pulsation  is  not  expansile,  and  ceases 
when  they  are  lifted  up  from  the  vessel ;  in  abscess,  in  addition 
to  the  absence  of  the  above  signs,  there  is  the  history  or  presence 
of  inflammation  ;  in  pulsating  goitre  the  tumor  moves  up  and 
down  with  the  larynx  on  deglutition.  The  treatment  consists  in 
pressure  or  ligature  of  the  artery  below  the  aneurysm,  or  if  there 
is  not  room  in  this  situation,  distal  ligature. 

Aneurysm  of  the  external  and  in'jernal  caroiids  requires  no 
special  mention.  Pressure  or  ligature  of  the  common  carotid  is 
the  treatment  generally  indicated. 

Orbital  aneurysm. — Several  conditions  may  give  rise  to  the 
group  of  symptoms  to  which  the  name  "orbital  aneurysm"  has 
been  applied.  In  only  one  instance  has  the  existence  of  a  circum- 
scribed aneurysm  in  the  orbit  been  verified  by  an  autopsy.    In  the 


AXILLARY   ANEURYSM.  289 

Other  cases  that  have  proved  fatal  the  following  conditions  were 
found:  i.  Thrombosis  of  the  cavernous  sinus.  2.  Communication 
between  the  carotid  artery  and  cavernous  sinus.  3.  Dilatation  of 
the  carotid  artery.  4.  Aneurysm  of  the  ophthalmic  artery  luithin 
the  cranium.  The  general  symptoms  are  :  Pulsation  over  the 
whole  or  part  of  the  orbit ;  protrusion  of  the  eyeball,  with  loss  or 
impairment  of  sight ;  more  or  less  pain  ;  and  a  loud  bruit,  which 
can  also  often  be  heard  by  the  patient  himself.  The  differential 
diagnosis  of  the  several  conditions  producing  these  symptoms  is 
one  of  great  difficulty,  and  cannot  be  entered  upon  here.  Treat- 
me}it. — The  symptoms  have  been  known  to  subside  spontaneously. 
Where  they  have  not  done  so,  hgature  of  the  carotid  has  been  at- 
tended with  the  best  results.  Injection  of  perchloride  of  iron  has 
been  recommended,  but  I  should  hesitate  to  use  it  myself  for  fear 
of  venous  thrombosis  and  embolism.  Where  the  pulsation  has 
followed  a  punctured  wound  of  the  orbit,  it  has  been  advised  to 
extirpate  the  globe  and  secure  the  bleeding  vessel  in  the  orbit. 
In  a  case  of  the  kind  recently  under  the  care  of  my  colleague, 
Mr.  Power,  ligature  of  the  common  carotid  was  attended  with 
perfect  success. 

Axillary  aneurysm  is  not  uncommon  as  the  result  of  sprains  or 
of  attempts  to  reduce  long-standing  dislocations  of  the  shoulder. 
The  diagnosis,  as  a  rule,  presents  no  difficulty,  except  the  aneur- 
ysm has  become  diffused,  when  it  may  be  mistaken  for  abscess. 
Treatment. —  1.  When  the  aneurysm  is  spontaneous,  small,  and 
well  circumscribed,  pressure  or  ligature  of  the  third  part  of  the 
subclavian  should  be  practiced.  2.  When  more  or  less  diffused, 
as  when  the  result  of  an  injury  to  the  artery  in  the  reduction  of  a 
dislocation,  the  aneurysm  should  be  cut  down  upon,  the  clots 
turned  out,  and  the  vessel  secured  above  and  below.  If  this  ope 
ration  is  decided  on,  an  incision  should  be  made  over  the  sub- 
clavian artery  through  the  skin  and  fascia,  so  that  pressure  may 
be  made  on  it  more  directly,  and  the  circulation  through  the 
aneurysm  during  the  subsequent  operation  better  controlled.  xA. 
small  incision  is  then  made  over  the  aneurysm,  two  fingers  are 
introduced  into  it,  and  placed  on  the  bleeding  spot  in  the  artery, 
which  may  be  known  by  the  hot  arterial  blood  issuing  from  it. 
An  assistant  in  the  meantime  enlarges  the  wound,  turns  out  the 
clots,  and  helps  the  surgeon  to  tie  the  artery  above  and  below  the 
rupture  before  the  fingers  are  removed.  This  method  is  less  dan- 
gerous than  that  practiced  by  Syme,  who  made  a  free  incision  over 
the  aneurysm,  rapidly  turned  out  the  clots,  and  seized  with  for- 
ceps the  bleeding  point  in  the  artery.  3.  Where  the  aneurysm  is 
of  great  size  and  involves  the  subclavian,  Macewen's  method  may 
be  employed  or  the  first  part  of  the  subclavian  or  the  innominate 
13 


290  DISE.\SES   OF   SPECIAL  TISSUES. 

may  be  ligatured,  or  iron  wire  introduced,  galvano-puncture  or 
manipulation  tried,  or  amputation  at  the  shoulder-joint  performed. 
Space  does  not  permit  of  a  discussion  of  the  cases  in  which  one  or 
other  of  these  methods  is  the  more  suitable.  All,  however,  with 
the  exception  of  Macewen's  method,  are  desperate  expedients. 

Aneurysms  at  the  bend  of  the  elbow  were  formerly  common 
when  venesection  was  in  vogue,  and  were  then  generally  arterio- 
venous in  character  (see  p.  202). 

Gluteal  aneurysm  is  the  term  applied  to  aneurysms  of  the 
gluteal  artery  itself,  the  sciatic,  or  the  pudic  where  it  winds  over 
the  spine  of  the  ischium.  Aneurysms  in  this  situation  may  be  the 
result  of  a  wound  or  other  injury,  or  may  occur  spontaneously. 
They  are  frequently  attended  with  pain  and  interference  with  the 
movements  of  the  hip-joint.  The  pulsation  and  bruit  will  gener- 
ally serve  to  distinguish  them,  but  there  may  be  no  pulsation,  as 
where  the  aneurysm  has  burst,  or  blood  has  been  effused  into  the 
tissues  as  the  result  of  a  wound  of  the  artery  ;  a  tumor  of  bone, 
moreover,  may  also  pulsate.  Under  such  circumstances,  explora- 
tion with  a  grooved  needle  will  be  necessary.  Treatment. — 
When  of  traumatic  origin,  an  incision  should  be  made  over  the 
tumor,  the  clots  turned  out,  and  the  bleednig  vessel  secured,  the 
haemorrhage  during  the  operation  being  controlled  by  pressure  on 
the  common  iliac  by  Davy's  lever  or  by  the  hand  in  the  rectum. 
^^'hen  spontaneous,  the  internal  iliac  may  have  to  be  tied  if  the 
aneurysm  encroaches  on  that  vessel  within  the  pelvis — a  point 
which  may  perhaps  be  determined  by  exploring  with  the  hand  in 
the  rectum.  Before,  however,  resorting  to  ligature  of  the  internal 
iliac,  Macewen's  method  or  compression  of  the  abdominal  aorta 
or  common  iliac,  and  carefully  applied  direct  pressure  on  the 
swelling,  should  be  tried.  Galvano-puncture  and  the  introduc- 
tion of  coagulants  have  been  employed  successfully  in  this 
aneurysm. 

Inguinal  aneurysms  are  those  which  involve  either  the  termina  ■ 
tion  of  the  external  iliac,  or  the  commencement  of  the  femoral. 
They  may  extend  either  upwards  along  the  course  of  the  iliac  into 
the  abdomen,  or  downwards  in  the  course  of  the  femoral  into  the 
thigh.  They  may  have  to  be  diagnosed  i'rom  enlarged  inguinal 
glands  over  the  artery,  tumors,  esix-cially  pulsating  tumors  of  the 
pelvic  bones,  and  abscesses.  From  abscess  and  tumor  they  may 
be  distinguished  by  the  signs  already  several  times  alluded  to.. 
Their  diagnosis  from  ])ulsatmg  tumors  of  bone  is  often  very  diffi- 
cult, and  the  external  iliac  has  before  now  been  tied  by  the  most 
able  surgeons  under  the  impression  that  such  a  tumor  was  an 
aneurysm.  The  diagnostic  points  have  already  been  given  under 
Pulsatile  Tumors  of  Botie  and  Diagnosis  of  Aneurysm  (pp.  235, 


POPLITEAL   ANEURYSM.  29 1 

276).  Treatment. —  i.  When  the  aneurysm  is  of  moderate  di- 
mensions, and  involves  only  a  small  portion  of  the  external  iliac, 
this  vessel  should  be  tied,  or  if  preferred,  an  attempt  may  first  be 
made  to  compress  it.  2.  Where  there  is  apparently  not  room 
to  apply  a  ligature  to  the  vessel,  rapid  compression  of  the  abdom- 
inal aorta  may  be  employed,  combined  in  some  cases  with  distal 
pressure.  3.  Where  there  is  not  room  for  the  tourniquet  on  the 
aorta,  medical  means  must  be  relied  on,  or  Macewen's  method 
tried.  This  faihng,  the  common  iliac  may  be  tied;  or  the  des 
perate  experiment  made  of  tying  the  aorta,  or  injecting  coagulants, 
or  passing  iron  wire  into  the  sac.  On  the  whole,  if  pressure  or 
Macewen's  method  fail,  ligature  of  the  common  ihac  by  the  in- 
traperitoneal method  perhaps  holds  out  the  best  chance  of 
success. 

Femoral  aneurysm  requires  no  special  remark  other  than  that 
when  situated  in  Hunter's  canal,  the  femoral  should  be  com- 
pressed or  tied  in  Scarpa's  triangle.  When  situated  in  Scarpa's 
triangle,  the  external  iliac  may  be  treated  in  the  same  way.  In 
either  situation  Esmarch's  bandage  may  be  used  if  this  method  of 
treatment  commends  itself  to  the  Surgeon's  judgment. 

Popliteal  aneurys^l — The  frequency  of  aneurysm  in  this  situa- 
tion is  attributed  to — i,  the  bifurcation  of  the  popliteal  artery 
into  the  anterior  and  posterior  tibial,  whereby  the  circulation 
through  it  may  be  slightly  obstructed,  or  an  embolus  be  readily 
impacted  ;  2,  the  artery  being  unsupported  by  muscles,  and  in 
contact  with  the  bone ;  3,  the  strain  en  the  artery  in  the  move- 
ments of  the  knee-joint;  4,  the  compression  that  may  be  exerted 
on  the  end  of  the  artery  by  the  strong  fibrous  arch  of  origin  of 
the  soleus  muscle.  A  popliteal  aneurysm  is  not  usually  difficult  to 
diagnose,  but  should  it  become  diffused,  suppurate,  or  break  into 
the  knee-joint,  it  may  be  mistaken  for  a  malignant  tumor  of  the 
bones,  an  abscess,  or  an  affection  of  the  joint.  The  history  of 
the  case,  the  consideralion  of  the  diagnostic  signs  of  aneurysm, 
already  given,  and  the  introduction  of  a  grooved  needle  into  the 
knee  when  blood  has  been  effused  into  the  joint,  will  usually  clear 
up  any  doubt  as  to  the  nature  of  the  affection.  A  popliteal  aneu- 
rysm is  often  bilateral.  Treatment. — Little  need  be  added  here 
to  what  has  already  been  said  on  the  general  treatment  of  aneu- 
rysm, as  such  especially  applies  to  aneurysm  in  this  situation. 
Flexion,  combined  with  appropriate  medical  treatment,  is  often 
successful ;  and  digital  and  instrumental  compression  are  especi- 
ally applicable  to  this  aneurysm,  or  an  Esmarch's  bandage  may 
be  used  if  preferred.  These  methods  failing  or  not  being  con- 
sidered advisable,  the  popliteal  in  the  upper  part  of  its  course  or 
the  femoral  artery  in  Scarpa's  triangle  should  be  tied.     The  opera- 


292  DISEASES   OF   SPECUL   TISSUES. 

tion  of  tying  should  be  done  at  once  under  the  following  circum- 
stances : — I.  When  the  aneurysm  is  rapidly  increasing  in  size, 
leaking,  or  threatening  to  burst.  2.  When  the  aneurysm  is  in- 
flamed but  has  not  suppurated.  3.  Under  some  circumstances 
when  it  has  burst  into  the  knee-joint.  4.  When  the  limb  is  oede- 
matous,  showing  that  the  vein  is  being  seriously  compressed.  5. 
When  the  patient  is  of  an  irritable  disposition,  addicted  to  alco- 
hol, and  impatient  of  control.  Amputation,  on  the  other  hand, 
is,  as  a  rule,  called  for: — i.  If  the  aneurysm  has  burst.  2.  If 
gangrene  has  set  in.  3.  If  suppuration  attended  with  profuse 
haemorrhage  has  occurred ;  and  4.  If  the  knee-joint  is  disorgan- 
ized. 

LIGATURE    OF    ARTERIES. 

The  ligatia-e  of  arteries  requires  a  knowledge  of  their  relational 
anatomy  and  of  the  position  and  appearance  of  the  various  struc- 
tures which  serve  as  guides  to  them.  Such  a  knowledge  can  only 
be  gained  in  the  dissecting  room,  and  by  the  frequent  practice  of 
operations  on  the  dead  body.  Here  only  the  chief  rules  that 
should  guide  us  in  applying  a  ligature,  and  a  short  account  ot 
the  methods  of  tying  the  more  important  arteries,  can  be  gii'en. 

General  rules  for  ligature : — i.  The  incision  should  generally 
be  made  parallel  to  the  course  of  the  artery,  and  the  skin  divided 
evenly  to  promote  union  by  first  intention.  2.  Each  successive 
cut  through  the  underlying  tissues  should  be  made  the  same 
length  as  that  through  the  skin,  and  bruising  of  the  parts  avoided 
as  much  as  possible.  3.  The  sheaths  of  muscles  and  tendons 
should  not,  if  possible,  be  opened.  4.  The  sheath  of  the  vessel 
having  been  exposed  and  the  artery  felt  pulsating  with  the  index 
finger,  the  sheath  should  be  pinched  up  with  forceps  and  opened 
by  cutting  with  the  blade  of  the  knife  on  the  flat.  5.  The  sheath 
being  opened,  it  must  be  separated  from  the  artery  in  the  whole 
of  its  circumference,  either  by  careful  dissecting  with  the  knife 
turned  with  its  edge  from  the  artery,  or  by  the  director  insinuated 
by  a  gentle  to-and-fro  movement  between  the  sheath  and  the 
artery.  If  this  part  of  the  operation  is  not  done  very  delicately, 
too  much  of  the  sheath  in  the  long  axis  of  the  artery  will  be  sejj- 
arated,  and  there  will  be  danger  of  secondary  hseniorrhage  from 
cutting  off  of  the  blood  supjjly  which  the  vessel  receives  from  its 
sheath.  6.  Having  separated  the  sheath,  one  side  of  it  should 
be  seized  with  the  forceps  and  the  needle  passed,  unthreaded, 
between  it  and  the  artery,  and  the  point,  by  a  gentle  to  and  fro 
movement,  carried  round  the  vessel  without  injuring  or  including 
any  of  the  contiguous  structures.  It  should,  save  in  exceptional 
cases  which  will  be  mentioned,  be  passed  from  the  side  on  which 


LIGATURE    OF    SPECIAL    ARTERIES.  293 

the  vein  lies.  7.  When  the  point  of  the  needle  projects  on  the 
opposite  side,  it  should  be  cleared  from  any  loose  cellular  tissue 
of  the  sheath  it  may  have  carried  before  it,  by  scratching  with  the 
finger-nail,  or  cutting  on  the  needle  with  the  edge  of  the  scalpel 
directed  from  the  artery.  8.  The  artery  should  be  gently  pressed 
between  the  curve  of  the  needle  and  the  finger  to  ascertain  that 
no  other  structure  is  included,  and  that  pressure  controls  the  pul- 
sation in  the  aneurysm.  9.  The  needle  should  now  be  threaded 
with  the  ligature  which  is  carried  round  the  artery  as  the  needle 
is  withdrawn  ;  the  ligature  should  then  be  tied  in  a  reef  knot  and 
its  ends  cut  off  short.  10.  Should  much  of  the  sheath  have  been 
unavoidably  separated  from  the  artery,  two  ligatures  had  better 
be  passed,  and  the  artery  divided  between  them.  I  question  if 
this  will  not  always  be  found  the  safer  method  :  it  is  now  the  one 
always  used  by  myself  and  by  several  of  my  colleagues  at  St.  Bar- 
tholomew's. II.  Some  form  of  aseptic  ligature  should  be  used, 
as  silk,  chromicized  catgut,  ox-aorta,  or  kangaroo- tail  tendon,  but 
the  best  material  can  hardly  be  said  to  have  been  determined.  I 
have  always  used  kangaroo-tail  tendon  myself,  and  have  found  it 
answer  admirably.  12.  The  wound  should  be  accurately  united, 
drained  if  deep,  and  dressed  antiseptically. 

Ligature  of  special  arteries  — The  common  carotid  artery 
may  require  tying  for — i.  Wound  of  the  artery;  2,  a  punctured 
wound  near  the  angle  of  the  jaw  or  tonsil ;  3,  aneurysm  of  the 
upper  part  of  the  artery  or  of  one  of  its  branches ;  4,  orbital,  in- 
tracranial and  cirsoid  aneurysm;  and  5,  aneurysm  at  the  root  of 
the  neck  (distal  ligature).  The  artery  may  be  tied  either  above 
or  below  the  omo-hyoid.  When  practicable  it  should  be  tied 
above,  as  it  is  here  more  superficial,  and  the  risk  of  suppuration 
extending  beneath  the  deep  fascia  into  the  chest  is  avoided. 
The  high  operation,  or  ligature  above  the  omo-hyoid. — Make  an 
incision  three  inches  in  length  with  its  centre  opposite  the  cricoid 
cartilage,  along  the  anterior  edge  of  the  sterno- mastoid  muscle, 
/.  ^.,  in  a  line  drawn  from  the  sterno-clavicular  articulation  to  a 
point  midway  between  the  angle  of  the  jaw  and  the  mastoid  pro- 
cess (Fig.  273,  i).  Divide  the  skin,  superficial  fascia,  platysma 
and  deep  fascia.  Draw  the  anterior  edge  of  the  sterno-raastoid 
gently  outwards,  and  the  artery  will  be  felt  pulsating  in  the  angle 
formed  by  the  omo-hyoid  with  the  sterno-mastoid.  Open  the 
sheath  on  its  inner  side,  and  pass  the  aneurysm  needle  from  with- 
out inwards  to  avoid  injuring  the  vein  which  slightly  overlaps  the 
artery  on  its  outer  side,  and  keep  its  point  close  to  the  vessel  lest 
the  pneumo-gastric  nerve  be  included  in  the  ligature.  The  small 
descendens  noni  nerve  runs  superficial  to  the  sheath,  and  if  seen, 
should  be  avoided.     The  superior  thyroid,  lingual  and  facial  veins 


J94 


DISEASES   OF   SPECIAL   TISSUES. 


Fig.  ioi. 


cross  the  artery  to  open  into  the  internal  jugular  vein.  Should 
they  impede  the  operation,  divide  them,  having  first  applied  two 
ligatures.     The  low  operation,  or  ligature  below  the  omo-hyoid. — 

Make  an  incision  in  the  same 
line  as  for  the  high  operation,  but 
lower  in  the  neck.  Draw  the 
sterno-mastoid  outwards  and  the 
sterno-hyoid  and  thyroid  inwards, 
and  the  artery  will  be  felt  beat- 
ing in  the  angle  formed  by  the 
omo-hyoid  with  the  sterno- thy- 
roid. Pass  the  needle  as  before 
from  without  inwards,  taking  es- 
pecial care  not  to  injure  the'^vein 
which  on  the  left  side  slightly 
overlaps  the  artery.  The  head 
should  be  kept  fixed  after  ligature 
by  sand  bags  or  some  form  of 
splint.  The  chief  dangers  after 
ligature  are — i.  Cerebral  mischief 
from  partial  cutting  off  of  the 
blood  supply  to  the  brain  ;  2,  a 
low  form  of  pneumonia  from  in- 
terference with  the  blood  supply 
of  the  pneumo-gastric  centre  ;  3, 
suppuration  descending  into  the 
mediastinum  ;  and  4,  suppuration 
of  the  sac  when  tied  for  aneurysm. 
The  collateral  circulation  (Fig. 
loi)  is  carried  on  by  the  anas- 
tomosis of —  I.  The  vertebral  with 
the  opposite  vertebral.  2.  The 
inferior  with  the  superior  thyroid. 
3.  The  internal  carotid  with  the 
opposite  internal  carotid  through 
the  circle  of  Willis.  4.  The  deep 
cervical  with  the  princeps  cervicis 
of  the  occipital.  5.  Branches  of 
the  external  carotid  with  the  cor- 
responding branches  of  the  oppo- 
site side  across  the  middle  line  of 
the  neck. 
The  exteknai,  and  in'iernai,  CARO'iin  aki fries  may  be  tied  by 
an  incision  similar  to  that  for  the  common  carotid,  but  higher  hi 
the  neck.     A  point  to  remember  is  that  the  internal  carotid  is  in 


Diacram  to  show  the  collateral  circulation 
after  ligature  of  common  carotid,  sub- 
clavian and  axillary  arteries.  A.  C'om- 
mon  carotid;  ii.  Internal  carotid;  C. 
E.\ternal  carotid;  D.  Vertebral;  E. 
Circle  of  Willis;  F.  Basilar;  c;.  Sub- 
clavian; H.  Thyroid  axis;  I.  Inferior 
thyroid;  j.  Superior  thyroid;  K.  Occipi- 
tal; L.  Princeps  cervicis;  M.  iJecp 
cervical;  N.  'I'ransvcisalis  colli;  <i. 
Suprascapular;  v.  Posterior  scapular; 
Q,  Dorsalis  scapulae;  R.  Infrascapular; 
s.  Subscapular;  T.  Long  thoracic;  i'. 
Short  thoracic;  v.  Superior  intercostal : 
X.  Internal  mammary;  y.  and  z.  Aortic 
intercostals. 


THE  BRACHIAL  ARTERY.  295 

position  at  first  external  to  the  external  carotid  and  of  larger 
size. 

The  ungual  artery  may  require  ligature  for  hsemorrhage  in 
cancer  of  the  tongue,  and  as  a  preliminary  to  excision  of  the 
tongue.  Make  an  incision  along  the  greater  cornu  of  the  hyoid 
bone  (Fig.  273,  g),  divide  the  skin,  superficial  fascia  and 
platysma  ;  hook  up  the  submaxillary  gland,  and  a  few  touches  of 
the  director  will  expose  the  triangle  bounded  below  by  the  anter- 
ior and  posterior  belly  of  the  digastricus  and  above  by  the  hypo- 
glossal nerve.  Scratch  cautiously  through  the  muscular  fibres  of 
the  hyo-glossus  which  forms  the  floor  of  this  triangle,  taking  care 
not  to  injure  the  hngual  vein  which  is  superficial  to  the  muscle  ; 
the  lingual  artery  will  be  seen  or  felt  lying  upon  the  middle  con- 
strictor of  the  pharynx.  The  vessel,  however,  is  often  abnormal, 
and  consequently  may  not  be  found  in  the  usual  situation. 

The  faclal  artery  is  readily  tied  at  the  anterior  edge  of  the 
masseter,  where  it  can  be  felt  beating.  It  lies  anterior  to  its  vein. 
It  has  frequently  to  be  tied  in  its  course  through  the  neck,  in  the 
removal  of  glands  from  that  region. 

The  superior  thyroid  artery  can  seldom  require  tying  except 
for  wounds  of  the  neck,  as  "cut  throat,"  and  as  a  pieliminary  to 
removal  of  the  thyroid  body. 

The  temporal  artery  may  require  ligature  for  cirsoid  aneurysm 
or  a  wound  of  the  vessel.  It  can  be  readily  secured  at  the  spot 
where  it  is  felt  beating  as  it  crosses  the  zygoma  just  in  front  of  the 
external  auditory  meatus  (Fig.  273,  h). 

The  subclavian  artery  may  be  tied  in  the  third  part  of  its 
course  for — i,  axillary  aneurysm  ;  2,  aneurysm  at  the  root  of  the 
neck  (distal  ligature)  ;  3,  ruptured  axillary  artery;  4,  secondary 
hsemorrhage  after  amputation  at  the  shoulder-joint;  and  5,  as  a 
preliminary  to  the  latter  operation.  The  head  having  been  drawn 
well  back,  the  face  turned  to  the  opposite  side  and  the  shoulder 
depressed,  draw  down  the  skin  over  the  clavicle,  make  an  incision 
along  the  middle  third  of  that  bone  through  the  integuments  and 
platysma,  so  as  to  avoid  injuring  the  external  jugular  vein,  and  let 
the  tissues  slip  up  again  (Fig.  273,  f).  Next  divide  the  deep 
fascia  on  a  director,  and  the  posterior  edge  of  the  sterno-mastoid 
will  be  exposed.  Hold  aside  or  divide  if  necessary  the  external 
jugular  or  any  other  vein  that  may  be  in  the  way,  but  do  not  in- 
jure the  suprascapular  artery,  as  this  is  one  of  the  chief  vessels 
by  which  the  collateral  circulation  will  subsequently  be  carried  on. 
Search  with  the  finger  and  director  for  the  scalene  tubercle  in  the 
triangle  bounded  by  the  omo-hyoid  above,  the  clavicle  below,  and 
the  scalenus  anticus  on  the  inner  side  :  the  artery  will  be  felt  pul- 
sating behind  the  tubercle.     It  has  the  vein  in  front  of  it,  but  on 


296 


DISEASES   OF   SPECIAL   TISSUES. 


Fig.  102. 


a  lower  plane,  and  the  brachial  plexus  above  it.  Pass  the  needle 
from  above  downwards.  The  artery,  if  necessary,  maybe  tied  in 
the  second  part  of  its  course  by  extendirg  the  incision  inwards  and 
partially  dividing  the  scalenus  anticus.  Ligature  of  the  first  part 
has  been  so  uniformly  fatal  hitherto  that  it 
will  not  be  described.  The  principal  acci- 
dents that  may  occur  during  ligature  of  the 
subclavian  in  the  third  part  of  its  course 
are — i,  injury  of  the  external  jugular  vein  or 
other  veins,  and  profuse  venous  haemorrhage  ; 
2,  wound  of  the  sac  of  the  aneurysm  ;  3, 
puncture  of  the  pleura ;  4,  inclusion  of  a 
cord  of  the  brachial  plexus  ;  5,  injury  of  the 
phrenic  nerve.  The  chief  dangers  after  /ig- 
ature  are  pleurisy,  secondary  haemorrhage, 
and  suppuration  of  the  sac.  The  collateral 
circulation  (Fig.  loi)  after  ligature  of  the 
third  portion  is  carried  on  by — i,  the  supra- 
scapular and  posterior  scapular  arteries  an- 
astomosing with  the  infra-scapular,  subscap- 
ular, and  dorsalis  scapulae  arteries  ;  2,  the 
internal  mammary,  superior  intercostal  and 
aortic  intercostal  arteries  anastomosing  with 
the  long  and  short  thoracic  arteries. 

The  AXii.LARV  artery  can  seldom  require 
ligature  except  for  wound  or  rupture  (p.  197). 
In  its  continuity  it  may  be  tied  in  the  first, 
second,  and  third  part  of  its  course.  In  the 
third  part  it  can  be  readily  secured  by  mak- 
ing an  incision,  with  the  arm  raised,  through 
the  skin  and  fascia  along  the  inner  border 
of  the  coraco-brachialis  and  biceps  (Fig. 
103,  b).  In  the  fi?-st  and  second  parts  of  its 
course  it  lies  below  the  pectoral  muscles,  and 
to  expose  it  so  deep  a  dissection  is  required, 
that  ligature  of  the  subclavian  is  p:eferable. 
The  collateral  circulation  (Figs.  lOi  and 
102)  after  ligature  of  the  first  portion  of  the 
axillary  is  carried  on  by  the  same  ve.isels  as 
after  ligature  of  the  third  pait  of  the  sub- 
clavian. After  ligature  of  the  third  part  of 
the  axillary  it  is  carried  on  chiefly  by  the 
anastomosis  of  small  branches  of  the  subscapular  and  circumflex 
above  with  similar  branches  of  the  superior  profunda  below. 
The  urachiai,  ar'j  krv  may  require  ligature  for — t,  wound  of  the 


Diagram  to  show  the  collat- 
eral circulation  after  lig- 
ature of  the  axillary, 
brachial  and  radial  and 
ulnar  arteries.  A.  Brach- 
ial; B.  Radial;  c.  Ulnar; 
D.  Superior  profunda;  E. 
Inferior  profunda;  F.  An- 
astomotica  magna;  G. 
Radial  recurrent;  H.  In- 
terosseous recurrent;  I. 
Anterior,  and  K.  posterior 
ulnar  recurrent;  j.  Axil- 
lary; I-.  Common  inter- 
osseous; M.  Posterior  in- 
terosseous; N.  Anterior 
interosseous;  o,  o.  An- 
terior and  posterior  car- 
pal ;  p.  Deep  palmar  arch ; 
Q.  Superficial  palmar 
arch;  v..  Posterior  cir- 
cumflex; s.  Subscapular. 


THE    RADIAL    AND    ULNAR    ARTERIES. 


297 


Fig.  103. 


artery ;  2,  aneurysm  at  the  bend  of  the  elbow ;  3,  wound  of  the 
pahnar  arch.  It  may  be  tied  in  any  part  of  its  course.  Make  an 
incision  (Fig.  103,  c),  along  the  inner  edge  of  the  biceps  in  a 
hne  drawn  from  the  anterior  fold  of  the  axilla  to  the  middle  of  the 
bend  of  the  elbow  through  the  integuments  and  deep  fascia,  avoid- 
ing the  basilic  vein  which  hes  over  the  course  of  the  artery  but 
superficial  to  the  fascia.  The  median  nerve  crosses  the  artery 
along  the  middle  of  its  course  from 
without  inwards.  At  the  bend  of  the 
elbow  make  the  incision  obliquely  from 
within  outwards  (Fig.  103,  d)  and  di- 
vide the  semilunar  fascia  of  the  biceps  : 
the  artery  will  be  found  between  the 
tendon  of  the  biceps  on  the  outer  side 
and  the  median  nerveon  the  inner  side. 
The  collateral  circulation  (Fig.  102) 
when  the  artery  is  tied  above  the  supe- 
rior profunda  is  the  same  as  that  after 
ligature  of  the  third  part  of  the  axillary. 
When  tied  below  the  superior  profunda 
it  is  carried  on  chiefly  by  the  anastomo- 
sis of  this  vessel  with  the  radial  and 
interosseous  recurrent  and  the  anas- 
tomotica  magna  ;  when  tied  below  the 
inferior  profunda,  by  the  additional  an- 
astomosis of  this  vessel  with  the  pos- 
terior ulnar  recurrent. 

The  RADIAL  AND  ULNAR  ARTERIES  may 

be  tied  for — i,  aneurysm  of  either  ves- 
sel, or,  2,  wound  of  the  palmar  arch  ; 
but  it  is  a  question  whether  ligature  of 
the  brachial  is  not  preferable  in  the 
latter  case,  as  the  anastomosis  between 

the  radial  and  ulnar  and  the  carpal  and  interosseous  arteries  is  so 
free  (Fig.  102).  Both  arteries  in  the  case  of  a  wound  of  the 
palmar  arch  need  to  be  tied.  This  is  best  done  at  thezorist,  where 
they  are  superficial  and  can  be  felt  pulsating.  The  radial  lies  be- 
tween the  supinator  longus  and  the  flexor  carpi  radialis  ;  the  ulnar 
between  the  innermost  tendon  of  the  flexor  sublimis  digitorum 
and  the  flexor  carpi  ulnaris,  by  which  latter  tendon  it  is  slightly 
overlapped.  An  incision  about  an  inch  long  through  the  integu- 
ments and  deep  fascia  parallel  to  the  course  of  either  vessel,  is  all 
that  is  necessary  to  expose  them  (Fig.  103,  g,  h).  In  the  case  of 
the  ulnar,  however,  the  flexor  carpi  ulnaris  may  have  to  be  held 
aside.     The  aneurysm  needle  should  be  passed  from  the  ulnar  to 


Lines  of  incision  for  ligature  of 
arteries  of  the  upper  extremity. 


298  DISEASES   OF   SPECIAL   TISSUES. 

the  radial  side  to  avoid  the  nerve  which  Ues  to  the  ulnar  side.  In 
the  case  of  the  radial  the  needle  may  be  passed  either  way,  as  the 
radial  nerve  at  the  wrist  is  not  in  contact  with  the  artery.  No 
harm  will  ensue  if  the  vense  comites  are  tied  with  their  respective 
vessels.  The  radial  artery  in  the  upper  third  lies  deeply  between 
the  supinator  longus  and  pronator  radii  teres.  Make  an  incision 
(Fig.  103,  e)  in  a  line  drawn  from  the  middle  of  the  bend  of  the 
elbow  to  half  an  inch  internal  to  the  styloid  process  of  the  radius. 
Separate  the  muscles  and  the  artery  will  be  exposed.  The  radial 
nerve  in  this  situation  is  some  distance  to  the  outer  side  of  the 
artery.  Ligature  of  the  ulnar  in  the  upper  third  is  more  difficult, 
as  it  lies  beneath  the  superficial  flexor  muscles.  Make  an  incision 
(Fig.  103,  f )  four  inches  long  in  a  line  drawn  from  the  front  of 
the  internal  condyle  to  the  radial  side  of  the  pisiform  bone.  Seek 
the  interval  between  the  flexor  carpi  ulnaris  and  the  flexor  sub- 
limis  digitorum.  Separate  these  muscles,  and  the  ulnar  nerve  will 
be  seen.  Work  superficial  to  the  nerve,  and  the  artery  will  be 
found  between  the  flexor  sublimis  and  flexor  profundus  digitorum. 
For  collateral  circulation  after  ligature  of  the  radial  and  ulnar 
arteries,  see  Fig.  102. 

The  external  iliac  artery  may  require  ligature  for — i,  Aneur- 
ysm in  the  groin;   2,  secondary  haemorrhage  from  the  femoral  ; 

3,  a  wound  of  the  vessel  itself.  A  line  drawn  from  half  an  inch 
below  and  a  little  to  the  left  of  the  umbilicus  to  the  middle  of 
Poupart's  hgament  indicates  its  course  Make  a  curved  incision 
beginning  a  little  external  to  the  centre  of  Poupart's  ligament  up- 
wards and  outwards  for  about  three  inches  towards  the  anterior 
superior  spine  of  the  ilium  (Fig.  284,  c).  Divide  the  skin,  super- 
ficial and  deep  fascia,  and  the  aponeurosis  of  the  external  ob- 
lique ;  cut  more  carefully  through  the  internal  oblique  and  trans- 
versalis  muscles,  and  the  fascia  transversalis  will  be  exposed. 
Divide  this  on  a  director,  taking  care  not  to  injure  the  peritoneum. 
Separate  the  peritoneum  gently  from  the  psoas  muscle,  and  let  an 
assistant  j)ress  it  carefully  upwards  and  inwards.  The  artery  will 
now  be  felt  beating  at  the  inner  ])art  of  the  wound  along  the  inner 
border  of  the  psoas.  Pass  the  aneurysm  needle  from  within  out- 
wards to  avoid  injuring  the  vein  which  lies  to  the  inner  side  of  the 
artery.  The  small  crural  branch  of  the  genito-crural  nerve  lies 
on  the  artery,  and  the  circumflex  iliac  vein  and  vas  deferens  cross 
it  just  before  it  passes  under  Poupart's  ligament.  The  chief  acci- 
dents that  may  occur  during  ligature  are  : — i.  Injury  of  the  peri- 
toneum ;  2,  wound  of  the  vein  ;  3,  wound  of  the  spermatic  cord  ; 

4,  wound  of  the  epigastric  artery  ;  and  5,  puncture  of  the  circum- 
flex iliac  vein,  'i'he  chief  dangers  after  ligature  are  : — 1,  (lan- 
grene   of  the   limb;    2,   ])eritonilis ;    3,  secondary  haemorrhage. 


THE  SUPERFICIAL  FEMORAL  ARTERY. 


299 


Fig. 


Should  secondary  haemorrhage  occur,  carefully  applied  pressure 
must  be  tried.  If  this  fails,  noth- 
ing is  left  but  the  desperate  ex- 
pedient of  cutting  down  on  the 
bleeding  vessel  and  trying  to 
secure  it.  Davy's  lever  should 
be  used  to  control  the  haemor- 
rhage during  the  operation.  The 
peritoneum  will  probably  be 
opened,  and  success  will  be 
problematical.  The  collateral 
circulation  (Fig.  104)  is  carried 
on  chiefly  by  the  anastomosis 
between  the  internal  mammary 
and  deep  epigastric  ;  the  iho- 
lumbar  and  circumflex  iliac  ;  the 
gluteal  and  external  circumflex; 
the  obturator  and  internal  cir- 
cumflex ;  the  sciatic  and  the 
superior  perforating  and  internal 
circumflex. 

The  cojbion  iliac  artery  has 
been  hgatured  for  aneurysm  of 
the  external  iliac  and  for  gluteal 
aneurysm ;  the  internal  iliac 
artery,  also  for  gluteal  aneur- 
ysm. Both  may  be  reached  by 
prolonging  the  incision  for  liga- 
ture of  the  external  iliac,  and 
both  have  recently  been  tied 
through  the  peritoneum.  Both 
operations  were  formerly  at- 
tended with  the  most  unfavor- 
able results,  but  of  late  there 
have  been  several  successful 
cases  in  which  the  abdomen  has 
been  opened  in  the  middle  line, 
the  intestines  drawn  aside  and 
the  vessels  exposed  by  scratch- 
ing through  the  peritoneum.  For 
collateral  circulation  see  Fig. 
104. 

The  superficial  femoral  ar- 
tery may  be  ligatured  for — i. 
Wound  of  the  artery  itself;  2,  popliteal  aneurysm  ;  3,  haemorrhage 


Diagram  of  the  collateral  circulation  after 
ligature  of  the  common  iliac,  external  and 
internal  iliac,  femoral,  popliteal,  and  arter- 
ies of  the  leg.  A.  Common  iliac:  B.  E.\- 
ternal  iliac;  c.  Internal  iliac;  D.  Last  lum- 
bar; E.  Ilio-lumbar;  F.  Epigastric;  g. 
Circumfle.x  iliac;  H.  Obturator,  i.  Glu- 
teal; J.  Lateral  sacral;  k.  .Sciatic;  l.  E,\- 
ternal  circumflex;  M.  Profunda;  N.  In- 
ternal circumflex;  o.  Femoral;  p.  Comes 
ischiatici;  OQQ.  Perforating;  k.  Anastom- 
otica  magna;  ss.  Superior  articular;  tt. 
Inferior  articular;  v.  Tibial  recurrent;  \. 
Popliteal;  \v.  Anterior  tibial;  x.  Posterior 
tibial;   v.  Peroneal. 


DISEASES    OF    SPECIAL   TISSUES. 


Fig.  105. 


from  a  wound  of  one  of  the  tibials.  The  ligature  may  be  applied 
either  in  Scarpa's  triangle  or  in  Hunter's  canal.  In  Scaj-pa's  tri- 
angle the  artery  is  usually  tied  at  the  apex  where  the  sartorius 
touches  the  adductor  longus.  If  thought  necessary,  the  line  of 
the  sartorius  may  be  marked  on  the  skin  with  lunar  caustic  by 
putting  the  muscle  in  action  before  the  patient  is  anaesthetized. 
Slightly  flex  the  leg,  and  place  the  thigh  on  its  outer  side  in  a  po- 
sition of  slight  abduction  and  flexion.  A  line  drawn  from  a  point 
midway  between  the  symphysis  pubis  and  the 
anterior  superior  iliac  spine  to  the  adductor 
tubercle  in  this  position  indicates  the  course 
of  the  artery  (Fig.  105,  a).  Make  an  incis- 
ion about  three  inches  long  in  this  line,  be- 
ginning about  four  inches  below  Poupart's 
ligament ;  cut  through  the  skin  and  super- 
ficial fascia,  and  divide  the  deep  fascia  on  a 
director.  Draw  the  sartorius  gently  outzvards 
and  the  sheath  of  the  vessel  will  be  exposed. 
Open  this  in  the  usual  way,  avoiding  the 
small  branch  of  the  internal  cutaneous  nerve 
which  crosses  the  artery  at  this  spot.  Pass 
the  aneurysm  needle  from  within  outwards  to 
avoid  injuring  the  vein  which  lies  to  the  inner 
side  of,  and  a  little  posterior  to.  the  artery. 
///  Hunter's  canal  the  same  line  as  the  above 
indicates  the  course  of  the  vessel  (Fig. 
105,  b).  Place  the  limb  as  before,  and  make 
an  incision  three  or  four  inches  long  in  the 
line  of  the  artery  in  the  middle  third  of  the 
thigh.  Divide  the  superficial  and  deep  fascia, 
and  the  sartorius  will  be  exposed.  It  may 
be  known  by  its  fibres  running  downwards 
and  inwards.  Draw  the  muscle  to  the  inner 
side,  and  the  aponeurotic  covering  of  Hun- 
ter's canal  (known  by  its  strong  transverse 
fibres)  will  be  seen.  Divide  it  on  a  director, 
and  the  artery  will  be  found  lying  between 
the  vastus  intcrnus  on  the  outer  side  and  the  adductor  longus  and 
magnus  on  the  inner  side.  The  vein  is  behind  and  a  little  ex- 
ternal to  the  artery.  The  long  saphenous  nerve  crosses  the  artery 
from  the  outer  to  the  inner  side.  Pass  the  aneurysm  needle  from 
without  inwards,  keeping  the  point  well  applied  to  the  vessel,  as 
the  vein  in  this  situation  is  usually  very  adherent  to  the  artery. 
The  chief  dangers  after  ligature  are — i,  gangrene  ;  2,  secondary 
haemorrhage  ;  3,  phlebitis  and   pyoemia  from   pricking  the  vein 


A 


liga- 


Lines  of  incision  for 
turc  of  arteries  of  lower 
extremity. 


THE    ANTERIOR    TIBIAL   ARTERY.  30t 

(see  p.  283).  The  collateral  circulation  (Fig.  104)  is  carried  on 
by  the  anastomosis  of  {a)  the  perforating  branches  of  the  pro- 
funda with  the  articular  branches  of  the  popliteal ;  {b)  the  de- 
scending branch  of  the  external  circumflex  with  the  external 
articular  branches  of  the  popliteal  and  tibial  recurrent ;  and  (<:) 
the  artery  of  the  great  sciatic  nerve  with  the  internal  articular 
branches  of  the  popliteal. 

The  POPLITEAL  ARrERY  may  be  ligatured  in  its  upper  part  for 
pophteal  aneurysm.  Place  the  limb  on  its  outer  side  and  make 
an  incision  about  four  inches  long  at  the  upper  part  of  the  pop- 
liteal space  over  the  course  of  the  artery.  Divide  the  deep  fascia 
and  feel  for  the  pulsation  of  the  vessel  at  the  inner  margin  of  the 
semi-membranosus.  Hook  the  nerve  outwards  or  inwards,  and 
open  the  sheath  well  to  its  inner  side  to  avoid  the  vein. 

The  POSTERIOR  tibial  artery. — In  the  upper  third.  Place  the 
limb  on  its  outer  side,  and  make  an  incision  four  inches  long  par- 
allel, and  half  an  inch  posterior  to  the  inner  border  of  the  tibia 
(Fig.  105,  e).  Divide  only  the  skin  and  superficial  fascia  in  the 
first  incision,  to  avoid  injuring  the  long  saphenous  vein.  Then 
divide  the  deep  fascia  and  draw  the  gastrocnemius,  if  seen,  back- 
wards ;  cut  through  the  tibial  origin  of  the  soleus,  and  the  inter- 
muscular fascia  will  be  exposed.  Divide  this  on  a  director,  and 
the  artery  will  be  found  lying  on  the  tibialis  posticus  with  the 
posterior  tibial  nerve  to  its  outer  side.  Ligature  of  the  posterior 
tibial  in  its  upper  third  can  hardly  be  required,  except  for  a 
wound  which  should  then  be  enlarged  longitudinally  until  suf- 
ficient room  is  obtained.  At  the  ankle. — Make  a  curved  incision 
over  the  artery  a  finger's  breadth  behind  and  below  the  internal 
malleolus.  Divide  the  superficial  and  deep  fascia  and  the  inter- 
nal annular  ligament,  and  the  artery  will  be  found  between  the 
tendons  of  the  flexor  longus  digitorum  and  flexor  longus  hallucis 
with  the  nerve  to  its  outer  side.  For  collateral  circulation,  see 
Fig.  104. 

The  anterior  tibial  artery. — A  line  drawn  from  the  inner 
side  of  the  head  of  the  fibula  to  midway  between  the  two  malleoli 
indicates  the  course  of  the  vessel.  /;/  the  upper  third  make  an 
incision  about  five  inches  long  in  the  line  of  the  artery  (Fig.  105, 
c)  through  the  skin  and  superficial  fascia  and  look  for  the  inner- 
most white  line,  which  indicates  the  cellular  interval  between  the 
tibialis  anticLi^  and  the  extensor  longus  digitorum.  Divide  the 
deep  fascia  over  this  fine  on  a  director ;  hold  the  muscles  apart 
by  retractors,  and  the  artery  will  be  found  on  the  interosseous 
membrane  with  the  nerve  to  its  outer  side.  ///  the  middle  third 
the  artery  lies  between  the  tibialis  anticus  and  extensor  proprius 
hallucis,  and  the  nerve  lies  on  the  artery.     In  the  lower  third  the 


302  DISEASES   OF   SPECIAL   TISSUES. 

artery  lies  between  the  extensor  proprius  hallucis  and  the  extensor 
longus  digitorum  with  the  nerve  on  its  outer  side.  An  incision  in 
the  line  of  the  artery  (Fig.  105,  d)  and  the  separation  of  the 
muscles  in  all  that  is  necessary  to  expose  the  vessel  in  either  of 
these  situations.     For  collatei-al  circulation,  see  Fig.  104. 

The  dorsalis  pedis  artery  may  require  ligature  for  a  wound 
on  the  dorsum  of  the  foot.  I  have  twice  seen  it  tied  for  aneurysm 
of  the  vessel  itself.  Make  an  incision  in  a  line  drawn  from  mid- 
way between  the  two  malleoli  to  the  interval  between  the  great 
and  second  toes  ;  divide  the  skin  and  the  superficial  and  deep 
fascia  :  the  artery  will  be  found  between  the  extensor  proprius 
hallucis  and  the  innermost  tendon  of  the  extensor  longus  digi- 
torum. As  the  artery  sinks  into  the  sole  it  is  crossed  by  the 
innermost  tendon  of  the  extensor  brevis  digitorum.  The  anterior 
tibial  nerve  is  on  the  outer  side. 

DISEASES    OF   THE   VEINS. 

Thrombosis,  or  clotting  of  the  blood  in  a  vein,  is  very  common, 
and  was  formerly  thought  to  be  always  the  result  of  inflammation 
of  the  vein-wall.  Hence,  whenever  a  vein  became  thrombosed,  the 
condition  was  spoken  of  as  phlebitis.  It  is  now  known,  however, 
that  a  thrombus  may  form  in  a  vein  without  any  inflammation  of 
its  walls,  and  that  the  presence  of  a  thrombus  is  in  some  cases  the 
cause  and  not  the  result  of  the  inflammation.  The  causes  of  throm- 
bosis may  be  considered  under  the  following  heads,  i .  Changes 
in  the  vein-wall,  such  as  may  result  from  injury,  inflammation  and 
degenerative  processes.  2.  Changes  in  the  blood,  such  as  occur 
in  septicaemia  and  pyaemia  and  other  affections  in  which  there  is 
a  destruction  of  the  white  corpuscles,  and  the  consequent  setting 
free  of  the  fibrin  ferment  contained  in  them.  The  exact  nature 
of  the  changes  in  the  blood  inducing  thrombosis  is,  however,  not 
known,  and  the  above  explanation  is  at  the  best  a  mere  theory. 
3.  The  presence  of  micro- oiganisms.  4.  The  retardation  or  arrest 
of  the  hlood-streavi,  as  («)  when  a  ligature  is  applied  to  a  vein; 
{b)  when  a  vein  is  compressed  by  a  tight  bandage,  tumor,  or  con- 
traction of  a  cicatrix;  {c)  when  the  blood  flows  feebly  through  a 
vein  owing  to  weak  action  of  the  heart  induced  by  age,  fevers, 
loss  of  blood,  etc.  5.  The  presence  of  a  foreign  body  not  covered 
by  endothelium,  as  a  piece  of  ligature,  an  embolus,  an  already 
formed  thrombus,  or  the  j)rotrusion  of  a  new  growth  into  the 
lumen  of  a  vein. 

Method  of  extension  of  the  thrombus. — When  once  formed  the 
thrombus  may  extend  either  with  or  against  the  blood-stream. 
As  a  rule,  however,  it  takes  the  former  direction,  extending  from 


DISEASES    OF   THE    VEINS.  3O3 

the  smaller  to  the  larger  veins,  and  in  this  way  may  at  times  reach 
the  heart. 

Appearances  of  a  recent  thrombus. — When  the  blood  is  at  rest 
at  the  time  of  coagulation,  as  when  a  vein  is  ligatured,  the  throm- 
bus will  be  red  throughout,  as  both  the  colored  and  colorless 
corpuscles  equally  become  entangled  in  the  fibrin.  It  will  fill  the 
whole  lumen  of  the  vein,  and  at  first  will  be  soft  and  gelatinous, 
and  but  loosely  attached  to  the  vein-wall.  When,  on  the  other 
hand,  the  clot  is  formed  gradually  whilst  the  blood  is  in  motion, 
as  when  the  clot  is  deposited  on  an  unhealthy  vein-wall,  the  clot 
is  laminated,  and  firmly  adherent  to  the  wall,  and  will  be  either 
white  or  tinged  with  red,  according  to  the  rate  at  which  it  is 
formed.  K  post-mortem  clot  may  be  distinguished  from  the  above 
in  that  it  does  not  adhere  to  the  wall  of  the  vessel,  nor  as  a  rule 
entirely  fill  its  lumen.  It  is  never  laminated,  although  it  may 
consist  of  two  layers,  one  white  and  one  red. 

Changes  in  the  thrombus. —  i.  The  clot  may  become  converted, 
together  with  that  portion  of  the  vein  in  which  it  is  contained, 
into  a  fibrous  cord.  Thus  it  first  loses  its  red  color  from  the  dis- 
appearance of  the  red  corpuscles,  then  becomes  firmer,  more 
adherent  to  the  wall  of  the  vein,  and  finally  indistinguishable  from 
it.  The  minute  changes  which  occur  in  this  process  are  similar 
to  those  already  described  in  the  healing  of  an  artery  after  injury 
(p.  127).  2.  The  clot  may  undergo  calcification  and  become 
converted  into  a  so-called  vein-stone  or  phlebolith,  which  may 
either  be  found  free,  or  attached  to  the  walls  by  a  pedicle.  3. 
The  clot  may  soften  and  disintegrate,  forming  a  pultaceous  red- 
dish material  or  a  yellowish-red  puriform  fluid,  the  latter  change 
being  probably  due  to  the  action  of  septic  micro  organisms.  4. 
The  clot  may  shrink  to  one  side  of  the  vein,  or  become  tunnelled 
by  the  blood,  or  it  may  be  slowly  carried  away  by  the  circulation 
without  causing  any  mischief.  The  tunnelling  of  the  clot  is 
brought  about  by  the  gradual  enlargement  of  the  small  vessels 
which  normally  permeate  the  clot  during  its  conversion  into  a 
fibrous  cord. 

The  effects  of  thrombosis  are,  i.  Swelling  and  oedema  of  the 
parts  from  which  the  affected  vein  returned  the  venous  blood. 
This  may  completely  or  partially  disappear,  or  it  may  remain 
permanent,  constituting  the  condition  known  as  solid  oedema,  ac- 
cording to  whether  the  lumen  of  the  vein  is  or  is  not  restored,  or 
the  collateral  channels  are  sufficient  for  the  requirements  of  the 
circulation.  A  good  example  of  oedema  from  thrombosis  is  fur- 
nished by  the  so-called  white  leg,  or  phlegmasia  alba  dolens,  so 
common  after  parturition  as  the  result  of  the  extension  of  the 
clot  from  the  uterine  veins  through  the  iliacs  to  the  femoral.     2. 


304  DISEASES   OF   SPECIAL  TISSUES. 

Gangrene  occasionally  occurs  after  the  plugging  of  a  large  vein, 
where  the  collateral  circulation  is  insufficient  to  relieve  the  en- 
gorgement of  the  part,  and  is  necessarily  of  the  moist  variety.  3. 
Phlehiiis,  or  inflammation  of  the  vein-walls,  may  ensue,  and  will 
take  a  simple  or  a  spreading  and  suppurative  form,  according  as 
the  thrombus  is  of  a  simple  or  of  a  septic  or  infective  nature.  4. 
Embolism,  owing  to  a  portion  of  a  thrombus  being  swept  away  by 
the  blood-stream  and  becoming  lodged  in  a  distant  vessel.  The 
way  in  which  this  detachment  may  take  place  is  shown  in  Fig. 
42,  p.  157.  If  the  thrombus  is  of  a  simple  character,  no  harm 
may  ensue ;  but  if  septic  or  infective,  the  embolus  will  also  be 
septic  or  infective,  and  set  up  a  like  inflammation  in  the  part 
where  it  becomes  arrested.     (See  Fycemia,  p.  155.) 

Signs. — When  the  deep  veins  are  plugged,  the  only  evidence  of 
the  thrombosis  will  be  signs  of  obstruction  to  the  circulation  in 
the  veins  below,  such  as  oedema  or  dilatation  of  the  superficial 
veins.  When,  however,  a  superficial  vein,  as  one  of  the  saphenas, 
is  affected,  there  will  be  a  hard  cord  like  swelling  in  the  situation 
of  the  vein,  and  some  tenderness  on  pressure  and  feehng  of  stiff- 
ness on  movement.  Should  inflammation  of  the  vein  follow  from 
the  presence  of  the  thrombus,  there  will  be  in  addition  some  heat 
and  redness  of  the  skin.      (See  Phlebitis.^ 

Treatment. — Absolute  rest  in  the  recumbent  position  is  essential, 
lest  a  portion  of  the  clot  should  become  detached  and  lodged  in 
an  important  organ,  as  the  brain,  or  plug  the  pulmonary  artery, 
and  sudden  death  ensue.  Where  there  is  much  oedema,  the  part 
should  at  first  be  elevated,  and  subsequently  evenly  and  firmly 
bandaged. 

FHLEiii'j'is,  or  inflammation  of  veins,  may  be  divided  into  the 
simple,  and  the  septic  or  spreading. 

Simple  phlebitis,  formerly  known  as  adhesive  phlebitis,  \'~.  a  simple 
local  inflammation  of  the  vein-wall,  and  may  terminate  in  resolu- 
tion, obliteration  of  the  vein,  or  more  rarely  in  the  formation  of  a 
localized  abscess.  Causes. — i.  Injury  of  the  vein-walls.  2. 
Simple  inflammation  of  the  surrounding  tissues.  3.  The  forma- 
tion of  a  non-infective  thrombus  in  a  vein.  4.  Gout,  or  the  gouty 
diathesis.  5.  ("ertain  conditions  of  the  system  the  exact  nature 
of  which  is  not  known,  the  phlebitis  being  then  spoken  of  as 
idiopathic. 

Pathology. — The  walls  of  the  vein  become  infiltrated  with  leuco- 
cytes and  swollen,  whilst  a  thrombus,  should  such  not  already  be 
present  as  the  cause  of  the  inflammation,  will  form  in  the  interior 
of  the  vein.  Changes  similar  to  those  already  described  under 
thrombosis  may  then  occur  in  the  clot.  Thus  the  vein  may  become 
obliterated,  or  the  thromljus  variously  disposed  of  and  the  calibre 


SUPPURATIVE    PHLEBITIS.  305 

of  the  vein  restored.  Or  pyogenic  organisms  may  gain  admission 
and  suppuration  may  take  place.  The  suppuration  however  does 
not  spread  unless  the  thrombus,  the  barrier  to  the  organisms,  is 
disturbed  on  the  evacuatioTi  of  the  pus. 

Symptoms. — There  is  the  same  cord-like  svvelhng  in  the  affected 
part  ot  the  vein  as  in  simple  thrombosis,  but  the  skin,  at  least  when 
a  superficial  vein  is  involved,  is  dusky-red  and  cedematous,  and 
pain  is  more  severe  on  pressure  and  on  movement.  When  a  vein 
of  large  size  is  affected,  there  will  be  in  addition  signs  of  obstruc- 
tion to  the  venous  circulation.  The  gouty  form  is  either  associ- 
ated with  ordinary  gouty  inflammation  in  the  foot  or  joints,  or 
occurs  with  little  or  no  evident  provocation  in  persons  of  marked 
gouty  constitution,  or  with  a  gouty  inheritance.  It  is  more  espe- 
cially characterized  by  its  symmetry,  apparent  metastasis,  and 
frequent  recurrences. 

The  t}-eatment  is  similar  to  that  of  thrombosis.  Where  there  is 
much  pain,  a  mixture  of  glycerine  and  belladonna  may  be  smeared 
over  the  vein,  or  lead  and  opium  lotion,  or  hot  boracic  poultices 
may  be  applied.  Should  an  abscess  form,  it  must  be  opened  with 
antiseptic  precautions,  care  being  taken  not  to  disturb  the  clots. 
SaUne  purgatives  should  be  given,  with  potash,  lithia,  piperazine, 
and  colchicum  in  the  gouty,  and  the  patient  placed  on  low  diet. 

Suppurative  phlebitis  is  a  spreading,  infective  inflammation  of 
the  vein-walls  and  tissues  around.  Causes. — It  is  due  to  an  in- 
fective inflammation  spreading  to  the  vein-walls,  or  to  the  softening 
of  an  infective  thrombus.  Thus,  it  is  frequently  met  with  in  con- 
nection with  compound  fractures,  ill-conditioned  stumps,  acute 
necrosis,  osteomyelitis,  diffuse  cellulitis,  malignant  pustule,  facial 
carbuncle,  etc.  It  may  also  follow  the  opening  of  an  abscess,  the 
result  of  simple  phlebitis,  if  the  clots  are  disturbed  and  septic  pro- 
cesses are  allowed  to  take  place  in  the  wound.  Pathology. — The 
coats  of  the  inflamed  vein  become  red,  swollen,  and  in  places  soft 
and  diffluent,  and  the  thrombus  softened  into  a  purulent  fluid, 
whilst  micrococci  are  found  both  in  it  and  in  the  vein-walls. 
These  changes  gradually  extend  up  the  vein,  and  should  portions 
of  the  infective  thrombus  be  carried  away  by  the  blood-stream, 
metastatic  abscesses  in  distant  parts  and  general  blood-poisoning 
will  result  {pyo'inia).  Symptoms. — When  a  superficial  vein  is 
affected  there  is  at  first  a  cord-like  sweUing  as  in  simple  phlebitis ; 
but  redness  and  oedema  of  the  skin  soon  supervene,  followed  by 
fluctuation  in  one  or  more  situations  in  the  course  of  the  vein, 
and  frequently  by  general  blood-poisoning.  When  the  deep  veins 
are  involved,  the  disease  may  not  be  suspected  until  signs  of  py?emia 
set  in,  and  the  condition  of  the  veins  can  then  only  with  certainty 
be  ascertained  on  a  post-mortem  examination  being  made.  The 
13* 


306  DISEASES    OF    SPECIAL   TISSUES. 

treatment  resolves  itself  into  controlling  or  arresting,  if  possible, 
the  infective  inflammation  in  the  part  from  which  the  suppurative 
phlebitis  starts.  Beyond  this,  little  can  be  done,  although,  could 
the  condition  of  the  veins  be  diagnosed  with  certainty,  amputation 
above  the  inflamed  part  might,  before  general  blood-poisoning  had 
super\-ened,  save  the  patient's  life,  ^^'hen  the  vein  is  superficial, 
cutting  out  a  piece  above  the  disease  has  been  suggested ;  but 
cases  to  which  such  treatment  would  be  applicable  must  be  very 
rare,  as  the  inflammation  is  seldom  limited  to  a  superficial  vein. 

Varicose  veins. — A  vein  is  said  to  be  varicose  when  it  is  per- 
manently and  unequally  dilated,  and  its  coats  have  undergone 
certain  degenerative  changes.  A  varicose  condition  is  most  com- 
mon in  the  veins  of  the  lower  extremities,  and  in  the  veins  of  the 
rectum  and  testicle  (see  Piles  and  Varicocele). 

The  causes  may  be  considered  under  the  heads  of  increased 
intra-venous  pressure,  and  changes  in  the  vein-walls.  A.  Increased 
intra-venous  pressure  may  be  due  to  i.  Organic  affections  of  the 
heart  whereby  the  return  of  venous  blood  is  impeded.  2.  Ob- 
struction to  the  circulation  in  the  portal  system,  a  cause  chiefly 
affecting  the  haemorrhoidal  veins  (see  Files).  3.  Pressure  upon 
the  veins,  such  as  may  be  exerted  {a)  by  the  gravid  uterus  or  a 
tumor  of  the  uterus  or  of  the  ovaries  on  the  iUac  veins ;  {b)  by 
an  aneurysm  of  the  abdominal  aorta  on  the  inferior  vena  cava ; 
{c)  by  faecal  accumulation  on  the  haemorrhoidal  veins  ;  (^i')  by  a 
tumor  in  the  groin  on  the  femoral  vein ;  {e)  by  an  ill  fitting  truss 
on  the  spermatic  veins  (see  Varicocele)  ;  or  {/)  by  a  tight  garter 
on  the  saphenous  veins.  4.  Long  standing,  which  has  a  tendency 
to  cause  the  accumulation  of  blood  in  the  veins  of  the  lower  ex- 
tremity. 5.  Severe  muscular  exertion,  whereby  an  increased 
amount  of  blood  is  driven  by  the  contraction  of  the  muscles  from 
the  deep  into  the  superficial  veins.  Some  authors  consider  this 
last  the  chief,  if  not  the  only  cause  of  varicose  veins  of  the  lower 
extremities.  They  maintain  that  the  pressure  of  the  blood  first 
produces  a  dilatation  of  the  superficial  veins  where  the  intermus- 
cular veins  empty  into  them  ;  that  this  dilatation  being  frequently 
repeated  becomes  permanent ;  that  the  valves  in  consequence  are 
unable  to  close  and  i)rotect  the  veins,  and  being  thrown  out  of 
use  gradually  undergo  atrophy,  whilst  the  weight  of  the  column 
of  blood,  from  the  inefficiency  of  the  valves,  becomes  further  in- 
creased, and  the  veins  still  further  dilated.  B.  Chan^^es  in  the 
vein-walls. — These  consist  principally  in  an  hereditary  weakness, 
want  of  muscular  tone,  and  inflammatory  softening  of  the  walls. 
Varicose  veins  are  more  common  in  men  than  in  women,  owing  to 
their  more  frecjuent  exposure  to  the  exciting  causes.  Women, 
however,  are  peculiarly  liable  to  them  during  pregnancy. 


VARICOSE  VEINS. 


307 


Fig.  106. 


Varicose  ■  veins.      (From 
Bryant's  Surgery.) 


Pathology. — ^A  varicose  vein  is  lengthened,  dilated,  and  fre- 
quently tortuous  (Fig.  106),  the  dilatation  being  especially  marked 
where  the  intermuscular  veins  open  into  the 
superficial,  and  at  the  situation  of  the  valves. 
The  middle,  and  to  a  less  extent  the  outer 
coat,  are  often  greatly  thickened  by  the  forma- 
tion of  fibrous  tissue,  but  the  inner  coat  shows 
little  change.  In  the  dilated  portions  im- 
mediately above  the  valves  the  coats,  on  the 
other  hand,  may  be  found  greatly  thinned,  so 
that  the  vein  maygive  way  at  these  situations. 
The  valves  themselves,  from  the  dilatation  of 
the  veins,  cease  to  be  of  service,  and  become 
atrophied  and  frequently  reduced  to  mere 
ridges  or  fibrous  cords.  Thus  the  intravenous 
pressure  in  the  segment  below  is  increased  as 
the  column  of  blood  in  the  upper  part  of  the 
vein  is  no  longer  supported  by  the  valves. 
The  deep  veins  are  generally  involved  in  the 
varicose  condition,  and  the  smaller  radicals 
returning  the  blood  to  the  varicose  vein  from 
the  skin  often  share  in  the  dilatation.  The  skin,  in  consequence 
of  the  obstruction  to  the  venous  return,  becomes  congested  and 
chronically  inflamed  {varicose  eczema),  and  frequently  gives  way, 
producing  an  ulcer  {varicose  ulcer)  ;  whilst  at  times  the  pressure 
of  the  vein  causes  thinning  of  the  skin,  and  this,  with  the  wall  of 
the  vein,  may  give  way,  and  haemorrhage  result.  When  the  valves 
have  been  destroyed,  the  hgemorrhage  may  be  very  severe,  and 
even  terminate  in  death,  as  the  blood  sometimes  flows  backwards 
from  the  heart  through  the  proximal  end  as  well  as  through  the 
distal  end  of  the  vein. 

The  symptoms  usually  complained  of  are  fatigue  and  a  sense  of 
fulness  of  the  limb-after  exercise  or  long  standing,  and  perhaps 
cramp,  coldness  of  the  feet,  swelHng  and  oedema  of  the  ankle,  and 
numbness  of  the  leg.  Sometimes  there  is  deep-seated  pain.  The 
tortuous  vein  or  veins  meandering  up  the  leg  is  a  characteristic 
sign  which  cannot  be  mistaken.  When  the  smaller  radicals  are 
affected,  bluish  clusters  of  minute  veins  are  visible  here  and  there, 
especially  about  the  ankle  and  knee. 

The  treatment  may  be  palliative  or  radical.  Palliative  treat- 
me7it  consists  locally  in  supporting  the  dilated  vein  by  an  elastic 
stocking  or  by  a  Martin's  or  an  ordinary  bdndage,  and  reducing 
the  hours  of  standing  where  possible,  The  bowels  at  the  same 
time  should  be  regulated,  and  the  general  health  improved  by 
tonics,  iron,  etc.     Radical  treatment  should  be  undertaken  under 


3o8  DfSEASES   OF   SPECIAL   TISSUES. 

the  following  circumstances — i,  when  a  vein  appears  likely  to 
burst;  2,  when  there  is  a  knotted  mass  of  large  veins  in  one  or 
more  situations  giving  rise  to  much  pain  and  inconvenience  ;  3, 
when  an  intractable  ulcer  is  present ;  and  4,  when  the  varicosity 
is  chiefly  confined  to  a  single  vein. 

Many  methods  of  operating  have  been  proposed.  The  object 
aimed  at  in  all  is  to  obliterate  the  vein,  either,  i,  by  exciting  ad- 
hesive inflammation,  as  by  acupressure,  coagulating  injections, 
ligature,  or  caustics ;  or  2,  by  excising  a  portion  of  the  vein  itself. 
Acupressure  consists  in  passing  a  needle  beneath  the  vein  in  sev- 
eral situations,  and  compressing  the  vein  between  the  needle  and 
a  piece  of  bougie  placed  over  the  vein  by  means  of  a  figure-of-8 
suture.  The  injections  chiefly  employed  are  perchloride  of  iron 
and  carbolic  acid.  If  they  are  used,  the  vein  should  be  com- 
pressed above  till  the  blood  at  the  spot  of  injection  has  had  time 
to  coagulate  ;  but  even  with  this  precaution  injection  is  a  danger- 
ous procedure,  and  one  I  would  not  myself  undertake.  If  a  sub- 
cutaneous ligature  is  employed,  it  should  consist  of  aseptic  silk  or 
chromicized  catgut.  The  caustic  method  consists  in  placing 
Vienna  paste  in  various  situations  over  the  vein  ;  it  sets  up  inflam- 
mation and  ulceration  of  the  skin,  which  spreads  to  the  vein  and 
causes  its  obliteration.  It  is  seldom  or  never  employed  at  the 
present  day.  Excision  of  a  portion  of  the  vein  after  a  ligature 
has  been  applied  above  and  below,  is  a  method  in  vogue  at  St. 
Bartholomew's  Hospital,  and  appears  on  the  whole  to  be  the  best 
and  most  certain  method  of  radical  cure.  A  small  incision  is 
made  over  the  vein,  the  vein  neatly  dissected  out  for  an  inch  or 
so,  a  catgut  ligature  applied  as  high  up  and  a  second  as  low  down 
as  possible  within  this  limit,  the  vein  between  the  ligatures  excised, 
and  the  little  wound  carefully  united  by  a  continuous  suture.  Five 
or  SIX  similar  incisions,  or  more  if  necessary,  are  made  along  the 
course  of  the  varicose  vein.  When  a  mass  of  tortuous  veins  is  the 
source  of  trouble,  it  should  be  dissected  out,  ligatures  having  been 
previously  applied  to  the  larger  veins  leading  from  the  mass. 
Whatever  operation  is  undertaken,  however,  the  patient  should  be 
kept  at  rest  in  the  recumbent  position,  to  prevent  a  portion  of  the 
thrombus  becoming  detached  and  the  consequent  danger  of  em- 
bolism in  vital  organs;  whilst  the  strictest  precautions  should  be 
taken  to  keep  the  wound  aseptic,  lest  supi)urativc  ]ihlebitis  ensue. 

NACVUS. 

There  are  two  chief  varieties  of  nsevus,  the  capillary  and  the 
venous,  but  both  forms  may  be  combined. 

'I'liE  CAi'ii-i.AKV  Nyi':vus  ox ptexiform  angioma  consists  of  a  mass 
of  dilated   and   tortuous  capillaries   boimd   together  by  a  scanty 


VENOUS    N^VUS.  "  309 

amount  of  connective  tissue.  These  nsevi  are  most  common  on 
the  head,  neck,  face  and  chest ;  and  occur  as  small,  flat,  or  slightly- 
elevated,  red  or  purplish-red  patches  on  the  skin  or  mucous  mem- 
brane. Sometimes  they  are  spread  out  as  a  thin  layer  covering 
perhaps  the  greater  part  of  one  side  of  the  face,  and  are  then 
known  2.%  port-wine  marks.  The  blood  can  be  pressed  out  mo- 
mentarily, but  returns  when  pressure  is  removed.  Their  rate  of 
growth  varies;  sometimes  it  is  quick,  at  other  times  it  is  slow;  or 
they  may  remain  stationary,  or  disappear  spontaneously.  Treat- 
ment.— The  smaller  naevi  may  readily  be  destroyed  by  nitric  acid 
or  ethylate  of  sodium.  Those  known  as  "  port-wine  marks" 
should  be  left  alone,  or  under  some  conditions  they  may  be 
scarified. 

The  venous  n^vus  or  cavernous  aiigioma  consists  of  a  number 
of  cavernous  spaces  lined  with  endothelium  and  communicating 
with  each  other,  and  with  the  arteries  on  the  one  hand  and  the 
veins  on  the  other.  These  nsevi  form  distinct  tumors  bound  to- 
gether by  delicate  connective  tissue,  sometimes  containing  fat. 
The  blood  in  them  is  of  a  dark  venous  color.  They  are  generally 
subcutaneous,  but  may  likewise  occur  beneath  a  mucous  mem- 
brane. They  are  always  congenital.  They  appear  as  irregular, 
nodular,  soft,  compressible  tumors,  easily  emptied  by  pressure, 
but  quickly  refilling,  and  swelling  up  on  coughing  or  crying. 
When  under  a  mucous  membrane  they  are  of  a  purplish-blue 
color.  The  skin  or  mucous  membrane  covering  them  may  be 
natural,  or  it  may  be  affected  with  the  capillary  variety  of  nsevus. 
Their  favorite  seats  are  the  lips,  cheeks,  scalp,  organs  of  genera- 
tion, back,  and  nates.  They  m.ay  gradually  increase  in  size, 
remain  stationary,  or  undergo  a  spontaneous  cure. 

Tt'eatment. — 'Fhe  indications  are  to  remove  or  to  destroy  the 
nsevus  with  as  little  scarring  as  possible.  This  may  be  done  by, 
I,  excision  with  the  knife  ;  2,  ligature  ;  3,  coagulating  injections  ; 
4,  setons  ;  5,  electrolysis. 

1.  Excision  with  the  knife  is  a  rapid,  painless,  and  effective 
method,  and  where,  as  in  the  lip,  by  removing  a  V-shaped  piece 
a  mere  hnear  scar  is  left,  is,  perhaps,  the  best.  To  avoid  hjemor- 
rhage,  however,  the  incision  should  be  made  wide  of  the  growth. 

2.  Ligature  is  a  sure,  simple,  and  safe  method,  but  is  painful, 
slow,  and  leaves  a  scar.  The  ligature  may  be  applied  in  several 
ways.  All  that  can  here  be  said  is  that  the  ligature  should  con- 
sist of  whip-cord  or  China  silk  ;  that  it  should  be  appHed  with  a 
naevus  needle,  either  subcutaneously,  or,  if  this  is  impracticable, 
through  an  incision  made  in  the  skin  round  the  naevus ;  and  that 
it  should  be  tied  tightly  in  a  reef  knot  to  ensure  complete  strangu- 
lation. 


3IO  DISEASES   OF   SPECIAL  TISSUES. 

3.  Coagulating  injections. — The  materials  most  often  used  are 
perchloride  of  iron,  carbolic  acid,  and  chloride  of  zinc.  Only  a 
drop  or  two  should  be  injected,  as  otherwise  sloughing  may  oc- 
cur, or  the  coagulation  may  spread  to  the  blood  in  the  veins,  and 
embolism,  resulting  perhaps  in  sudden  death,  may  ensue.  To 
avoid  this  accident  the  base  of  the  n^evus  must  be  compressed  by 
a  clamp  or  a  ligature  during  and  for  a  short  time  after  the  opera- 
tion.    Injection  at  the  best  is  a  dangerous  method. 

4.  Setons. — A  simple  thread,  or  one  soaked  in  perchloride  of 
iron,  passed  through  the  nsevus  and  left  in  for  a  week,  may  effect 
a  cure  by  causing  adhesive  inflammation.  This  method  is  some- 
times useful  where  others  are  inappHcable. 

5.  Electrolysis  is  indicated  when  it  is  important  to  save  the 
skin  and  reduce  the  scar  to  a  minimum,  as  in  venous  naevi  about 
the  face.  It  consists  in  passing  two  or  more  needles  into  the 
naevus  in  different  situations,  and  sending  a  weak  constant  current 
through  them  ;  or  better,  passing  needles  connected  only  with 
the  negative  pole  of  the  battery  into  the  nsevus,  and  rubbing  a 
rheophore  connected  with  the  positive  pole  over  the  skin  of  some 
other  part  of  the  body.  Should  bubbles  of  gas  escape  the  current 
must  be  reduced  in  strength.  Before  removing  the  needles  from 
the  nsevus  the  current  should  be  reversed  for  a  few  seconds,  in 
order  that  the  salts  of  iron  may  be  formed  around  the  needles, 
and  so  prevent  bleeding  from  the  punctures.  The  operation  must 
be  repeated  many  times,  as  if  too  strong  a  current  is  used  slough- 
ing will  take  place. 

Arterial  varix,  or  a  dilated,  tortuous  and  irregularly  pouched 
condition  of  an  artery  similar  to  that  of  a  vein  in  varix,  cirsoid 
ANEURYSM,  or  a  pulsating  tumor  composed  of  several  lengthened, 
dilated  and  pouched  arteries,  and  nearly  always  situated  on  the 
scalp,  and  aneurysm  by  anastomosis,  or  a  localized  dilatation  of 
arteries,  veins,  and  capillaries — are  all  too  rare  to  require  de- 
scription here.  Excision  after  ligature  of  the  supplying  vessels  is 
perhaps  the  best  treatment. 

DISEASES    OF    THE    LYMPHATICS. 

Lymphangitis  or  inflammation  of  the  lymphatic  vessels  is  gen- 
erally associated  with  more  or  less  inllammation  of  the  lymphatic 
glands.  Causes. — The  most  common  cause  is  the  absorjition  of 
septic  or  of  infective  products  from  a  wound,  which,  however,  is 
often  very  trivial,  such  as  a  simple  scratch,  abrasion,  sting,  or 
puncture  ;  more  rarely,  the  inflammation  may  follow  upon  mere 
irritation  of  the  skin,  as  a  chafe  of  the  heel,  excessive  friction,  or 
sun-burn.     Pathology. — The  walls  of  the  lymphatics  become  in- 


LYMPHADENITIS.  3 1 1 

filtrated  with  cells,  swollen,  and  softened,  whilst  the  endothelium 
is  shed,  and  the  lymph  contained  in  the  vessels  often  undergoes 
coagulation.  The  inflammation  spreads  to  the  surrounding  tis- 
sues, but  seldom  higher  in  the  course  of  the  lymphatics  than  the 
first  set  of  glands,  which  also  become  swollen  and  infiltrated  and 
arrest  the  further  absorption  of  the  septic  products.  It  may 
terminate  in  resolution,  or  in  suppuration  in  and  around  the 
glands,  or  more  rarely  around  the  lymphatics  themselves.  Some- 
times the  septic  products  appear  to  escape  the  glands,  and  gen- 
eral blood-poisoning  ensues.  Symptoms. — In  severe  cases,  lym- 
phangitis generally  begins  with  a  chill  or  rigor,  followed  by  high 
temperature  and  fever,  and  perhaps  vomiting  and  diarrhoea.  Red 
hnes,  when  the  superficial  lymphatics  are  affected,  are  seen  run- 
ning from  the  wound  to  the  nearest  lymphatic  glands,  with  here 
and  there  erysipelatous  patches  of  redness.  There  is  generally 
pain  and  tenderness,  especially  in  the  region  of  the  swollen  glands, 
and  swelling  and  oedema,  sometimes  of  the  whole  limb.  It  may 
be  diagnosed  from  phlebitis  by  the  redness  being  superficial  and 
in  the  course  of  the  lymphatics,  not  in  the  course  of  the  veins; 
by  the  absence  of  the  cord-like  and  knotty  feel  of  plugged  veins, 
and  by  the  presence  of  glandular  enlargement ;  from  erysipelas 
by  the  redness  having  no  defined  margin,  and  generally  running  in 
lines.  The  treatment  consists  in  attending  to  any  wound  or 
abrasion,  allaying  other  sources  of  irritation  that  may  be  present, 
and  placing  the  inflamed  part  at  rest  in  an  elevated  position. 
Hot  fomentations  or  poultices,  or  glycerine  and  belladonna,  may 
be  applied,  and  abscesses  should  be  opened  as  soon  as  they  form. 
If  any  swelling  is  left,  pressure  in  the  form  of  Scott's  dressing  or 
ammoniacum  and  mercury  plaster  may  be  used  to  disperse  it. 

Lymphatic  varix  or  Lymphangiectasis  is  very  rare.  It  is  at- 
tended by  a  condition  of  elephantiasis  of  the  parts  where  the  lym- 
phatics are  blocked.  When  the  superficial  vessels  are  affected, 
"  the  varix  first  appears  in  the  form  of  small  elevations,  giving  the 
skin  an  appearance  which  has  been  compared  to  the  rind  of  an 
orange.  It  subsequently  takes  the  form  of  little  vesicles,  covered 
with  a  thin  layer  of  dermis."  (Erichsen.)  At  times  the  dilated 
lymphatics  form  distinct  tumors  {Lymphangiomata) .  Treatment. 
— Slight  elastic  pressure,  and  protection  from  injury  or  irritation. 

Lymphatic  fistula  or  Lymi'HOrrhcea,  though  exceedingly  rare, 
is  a  condition  sometimes  met  with,  and  more  especially  in  the 
groin,  scrotum,  or  labium.  It  is  said  to  be  due  to  a  wound  of  a 
lymphatic,  or  to  the  giving  way  of  a  varicose  lymphatic,  but  the 
cause  is  not  clearly  understood. 

Lymphadenitis,  or  inflammation  of  the  lymphatic  glands,  may 
be  acute,  subacute,  or  chronic. 


312  DISEASES   OF   SPECIAL   TISSUES. 

Acute  or  subacute  inflammation  is  nearly  always  secondary  to 
inflammation  of  the  parts  from  which  the  afferent  lymphatics  pro- 
ceed. Indeed,  in  most  inflammations,  there  is  some  tenderness 
of  the  neighboring  glands.  The  lymphatic  vessels  themselves, 
although  the  glands  may  become  extensively  involved,  and  even 
suppurate,  often  escape.  The  inflammation,  however,  rarely  pro- 
ceeds further  in  the  course  of  the  lymphatics  than  the  first  series 
of  lymphatic  glands,  although  it  often  spreads  to  the  surrounding 
tissues  {peri'lymphadenitis).  The  changes  in  the  inflamed  gland 
are  like  those  of  other  inflammations.  The  whole  gland  is  en- 
larged, the  vessels  dilated,  and  the  lymph-sinuses  crowded  with 
cells.  Micro-organisms,  similar  to  those  found  in  the  inflamma- 
tory lesion  giving  rise  to  the  lymphadenitis,  have  been  discovered 
in  the  glands.  The  sigjis  are  tenderness,  heat,  pain  and  swelling, 
followed  by  redness  of  the  skin  and  cedema.  The  gland,  at  first 
movable,  becomes  fixed,  and  if  the  process  runs  on  into  suppura- 
tion, the  usual  signs  of  an  abscess  ensue.  P'amiliar  examples  of 
lymphadenitis  are  seen  in  the  bubo  of  gonorrhoea,  in  the  tender 
glands  of  erysipelas,  and  in  the  suppurating  bubo  of  soft  chancre. 
The  treatuieiit  consists  in  subduing  the  inflammation  of  the  part 
from  which  the  lymphatics  proceed,  painting  the  glands  with  gly- 
cerine and  belladonna,  applying  a  hot  poultice,  and,  if  suppuration 
has  occurred,  in  making  a  free  incision.  Some  surgeons  dissect 
out  the  glands  if  suppuration  threatens. 

Chronic  lymphadenitis  is  very  common  in  strumous  children, 
especially  in  the  neck.  The  affection  of  the  glands  can  frequently 
be  traced  to  some  exciting  cause,  as  the  irritation  of  pediculi  on 
the  head,  eczematous  affections  about  the  mouth,  enlarged  ton- 
sils, or  carious  teeth.  In  other  cases,  it  depends  upon  the  pres- 
ence of  the  tubercle  bacillus.  See  Tubercle,  p.  58.  The  glands 
slowly  enlarge,  and  become  infiltrated  with  small  round  cells ; 
whilst  in  the  tubercular  cases,  non-vascular  areas  containing  giant 
cells,  lymphoid  corpuscles,  and  tubercle  bacilli  are  found.  The 
enlargement  may  subside,  or  the  inflammatory  products  may 
caseate,  and  suppuration  occur  in,  or  in  and  around  the  gland  ;  at 
times,  the  caseous  mass  may  dry  up  and  become  cretaceous,  or 
atrophy  or  fibroid  thickening  may  ensue.  In  rare  instances  it  is 
said  the  tubercle  may  become  disseminated,  leading  to  general 
tuberculosis.  Signs. — The  glands,  when  those  of  the  neck  (the 
most  common  situation)  are  affected,  become  enlarged  on  one  or 
both  sides  of  the  neck,  without  pain.  They  are  at  first  distinct 
and  movable,  but  later  often  coalesce  and  become  adherent  to  the 
surrounding  parts.  After  a  time,  they  may  soften  and  break 
down  ;  the  skin  then  becomes  adherent  and  red,  gives  way,  and  a 
curdy  pus  is  exuded.     After  the  abscess  has  been  opened,  a  por- 


LYMPHADENOMA.  3  T  3 

tion  of  the  broken-down  gland  may  be  seen  in  the  floor  of  the 
ulcer,  the  edges  of  which  are  bluish  pink,  and  undermined.  See 
Tubercular  Ulcers.  The  ulcers  are  very  indolent,  and  when 
finally  healed,  leave  characteristic  raised,  puckered,  pinkish-white 
scars.  Concomitant  signs  of  struma  or  tubercle  are  frequently 
present.  Treatment. — And  source  of  irritation,  such  as  pediculi, 
carious  teeth,  etc,  should  be  sought  and  removed,  and  the  patient, 
if  tuberculous,  treated  as  indicated  at  p.  63.  The  glands  had  bet- 
ter be  left  alone,  unless  suppuration  threatens,  when  they  should 
be  removed.  If  an  abscess  has  already  formed,  it  should  be 
opened  early  to  prevent  scarring.  This  may  be  done  by  a  small 
incision,  after  which  the  capsule  of  the  gland  may  be  cleared  out 
by  a  Volkmann's  spoon.  Should  an  indolent  ulcer  or  sinus  re- 
main, as  often  happens  if  the  abscess  is  allowed  to  burst  spontane- 
ously, it  should  also  be  scraped  with  a  Volkmann's  spoon  and  its 
edges  destroyed  by  nitrate  of  silver  or  potassa  fusa,  or  better,  cut 
away. 

Lymphadenoma,  or  non-inflammatory  enlargement  of  the  lym- 
phatic glands,  consists  of  a  simple  hypertrophy  of  the  gland  tissue, 
especially  of  the  fibrous  stroma  of  the  gland,  and  is  often  associ- 
ated with  leukcemia,  or  an  increase  of  the  white  corpuscles  of  the 
blood,  and  with  a  general  hypertrophy  of  the  adenoid  tissue  of 
the  body,  especially  of  the  spleen.  The  cause  is  unknown.  One 
or  two  glands  only  may  be  affected  (^simple  lymphadeiioina  or 
lymphoma),  or  many  of  the  glands,  especially  those  in  the  neck, 
axilla,  and  groin,  or,  indeed,  all  the  glands  of  the  body,  together 
with  the  adenoid  tissue  in  other  organs  {Hodgkin's  disease).  The 
enlargement  differs  from  that  of  the  inflammatory  affections,  in 
that  the  glands  remain  free  and  distinct,  and  form  smooth, 
rounded  or  egg-shaped,  firm,  elastic,  and  generally  painless  swell- 
ings, which,  as  a  rule,  do  not  suppurate.  When  one  or  two  glands 
only  are  enlarged,  the  general  health  is  not  affected ;  but  when 
many  are  involved,  and  especially  when  associated  with  a  leu- 
ksemic  condition,  the  patient  rapidly  emaciates,  becomes  anaemic, 
the  spleen  enlarges,  diarrhoea  or  dropsy  may  set  in,  and  death 
usually  results  from  exhaustion,  or,  it  may  be,  from  the  pressure 
of  the  enlarged  glands  upon  the  trachea,  bronchi,  or  some  vital 
organ.  Treatment. — Where  one  or  two  glands  alone  are  enlarged, 
they  may  be  removed ;  but  where  large  numbers  are  affected,  no 
surgical  treatm.ent  is  of  any  avail,  although  if  a  gland  is  pressing 
upon  the  trachea,  etc.,  it  may  be  removed,  or  tracheotomy  per- 
formed. In  the  non-leuksemic  forms,  arsenic,  in  increasing  doses, 
may  be  given  internally,  with  iron  and  cod  liver  oil,  or  chloride 
of  calcium  in  ten-grain  doses  may  be  tried.  For  the  treatment 
of  the  disease  when  associated  with  leukcemia,  see  a  work  on 
Medicine. 
14 


314  .  DISEASES   OF   SPECIAL   TISSUES. 

LvMPHO-SARCOMA  is  the  term  sometimes  applied  to  primary 
sarcoma  occurring  in  a  lymphatic  gland.     (See  Sarcoma,  p.  88.) 

DISEASES   OF   NERVES. 

Neuritis,  or  inflammation  of  nerves,  occurs  in  the  sheath  or 
connective  tissue  binding  the  nerve- fibres  together,  and  is  there- 
fore a  perineuritis,  or  interstitial  neuritis,  and  not  an  inflammation 
of  the  nerve-substance.  Causes. — Injury,  cold,  rheumatism, 
syphilis,  tubercle,  lead-poisoning,  gout,  diphtheria,  alcoholism, 
and  fevers.  Pathology. — In  the  acuter  forms,  the  nerve  appears 
slightly  red  and  swollen,  and  later  infiltrated  with  inflammatory 
exudation.  In  the  more  chronic  cases  the  sheath  and  interstitial 
connective  tissue  appear  thickened,  whilst  the  nerve-iibres  are 
more  or  less  atrophied.  When  following  an  amputation,  partial 
division  with  laceration,  or  gunshot  injury,  the  inflammation  gen- 
erally spreads  up  the  nerve  from  the  seat  of  injury  {ascending 
neuritis).  Symptoms. — There  may  be  tenderness  on  pressure,  or 
continuous  pain  with  exacerbations,  in  the  course  of  a  nerve  and 
its  peripheral  branches,  tingling  and  numbness  in  the  part  sup- 
plied by  it,  and  occasionally  spasm  of  the  muscles.  The  pain  is 
generally  worse  at  night,  and  increased  on  movement.  At  times 
the  nerve  may  be  felt  to  be  swollen,  and  there  may  be  loss  of  sen- 
sation or  muscular  paralysis  in  the  part  it  supplies.  The  acute 
cases  are  attended  with  slight  fever.  In  the  traumatic  form,  pres- 
sure at  the  seat  of  injury,  or  over  the  bulbous  end,  may  cause 
great  pain  and  muscular  spasm.  Treatment. — The  cause,  if  pos- 
sible, should  be  removed,  alcohol  forbidden,  and  appropriate 
remedies  given  if  there  be  gout,  syphilis,  or  signs  of  lead- 
poisoning,  etc.  Locally  hot  fomentations  or  leeches,  or  bella- 
donna and  glycerine  may  be  apphed,  and  later,  blistering  fluid 
along  the  course  of  the  nerve.  Absolute  rest  of  the  part  supplied 
by  the  nerve  is  imperative.  In  the  traumatic  form  following 
amputation,  stretching  the  nerve  relieves  for  a  time;  but  cutting 
out  the  bulbous  end,  division  of  the  nerve,  or  resection  of  a  por- 
tion, though  said  to  do  good,  have,  in  my  experience,  failed  to  do 
so.     Percussion  of  the  nerve  is  well  spoken  of  by  some. 

Neuralgia  is  the  term  applied  to  pain,  generally  of  a  paroxys- 
mal and  violent  character,  in  the  course  or  distribution  of  a 
sensory  or  mixed  nerve.  The  catises  of  neuralgia  are  very  various. 
Thus,  it  may  be  due  to — i,  pressure  on  a  nerve  by  a  tumor  or 
aneurysm,  or  involvement  of  its  end  in  a  scar ;  2,  the  presence  of 
a  foreign  body  in  a  nerve  ;  3,  inflammation  of  a  nerve  from  injury, 
exposure  to  cold,  etc. ;  4,  irritation  or  injury  of  another  nerve  or 
its  endings,  transferred  or  reflected — e.g.,  supraorbital  neuralgia 


NEURALGIA.  3 1 5 

due  to  carious  teeth,  pain  in  the  back  consequent  on  uterine  dis- 
ease ;  5,  some  constitutional  condition,  as  debility  induced  by 
excessive  child-bearing,  mental  depression,  hysteria,  influenza, 
malaria,  etc. ;  6,  disease  of  the  central  nervous  system  ;  7,  un- 
known causes.  Sy??iptoms. — The  usual  sign  is  pain  in  the  distri- 
bution or  course  of  a  nerve  or  of  several  nerves,  generally 
violent,  shooting,  paroxysmal,  and  tingling.  At  times  it  may  be 
attended  with  spasm  of  the  muscles,  hypersecretion  of  the  glands, 
and  derangements  of  pigmentation  of  the  hair  and  skin.  The 
pain,  except  when  it  depends  upon  neuritis,  may  often  be  relieved 
by  pressure.  It  is  most  common  in  the  fifth  nerve,  trigeminal 
neuralgia  {tic  douloureux),  in  the  sciatic  nerve  {sciatica),  and  in 
the  intercostal  nerves  {pleurodynia).  At  other  times  it  is  local- 
ized to  an  organ,  as  the  testis  or  the  breast,  or  to  a  joint.  A 
severe  form  of  trigeminal  neuralgia  known  as  epileptiform  neural- 
gia or  incurable  tic,  may  affect  one  or  more  of  the  branches  of 
the  fifth  nerve.  The  paroxysms  are  of  short  duration,  but  of  a 
most  excruciating  character ;  they  recur  at  varying  intervals,  and 
are  brought  on  by  the  slightest  cause,  as  pressure  over  the  bony 
canal  through  which  the  nerve  emerges  on  the  face,  a  draught  of 
cold  air,  taking  food,  etc.  The  pathology  of  it  is  quite  unknown. 
Simple  neuralgia,  i.  e.,  pain,  the  cause  of  which  is  not  apparent, 
often  simulates  organic  disease.  Thus,  pain  in  the  course  of  an 
intercostal  nerve  may  simulate  pleurisy  ;  neuralgia  in  a  joint, 
joint  disease.  It  may  be  distinguished  from  such  by  the  absence 
of  signs  of  inflammation,  of  deep  seated  pain,  and  of  swelling  and  . 
deformity;  by  the  presence  of  increased  cutaneous  sensibility; 
and  often  by  the  fact  that  firm  pressure  relieves  it.  Sciatica, 
or  pain  in  the  course  of  the  sciatic  nerve,  may  be  a  simple  neu- 
ralgia, depending  upon  some  central  and  unknown  cause  ;  or  it 
may  be  due  to  a  neuritis  set  up  by  cold,  or  a  blow  causing  local 
effusion  in  the  nerve-sheath,  or  an  adhesion  between  the  nerve 
and  its  sheath,  a  spiculum  of  bone  or  exostosis  pressing  upon  the 
nerve  especially  in  its  passage  through  the  great  sciatic  notch,  a 
foreign  body  in  the  thigh,  pelvic  inflammation  in  connection  with 
pregnancy,  or  the  pressure  of  a  tumor.  When  due  to  a  neuritis, 
it  is  accompanied  by  more  or  less  muscular  atrophy. 

Treatment. — The  first  indication  is  to  remove  the  cause,  for 
which  a  careful  search  should  be  made.  Thus,  carious  teeth 
should  be  extracted,  foreign  bodies  removed,  etc. ;  the  general 
health  improved  by  tonics,  iron,  quinine,  fresh  air,  etc. ;  and 
gouty,  rheumatic,  or  other  constitutional  diatheses  combated  by 
appropriate  means.  When  no  cause  can  be  discovered,  the  treat- 
ment must  necessarily  be  empirical;  and  when  one  remedy  fails, 
another  must  be  tried.     Thus,  internally,  quinine  in  large  doses, 


l6  DISEASES   OF   SPECIAL  TISSUES. 


arsenic,  aconitine  beginning  with  inn  of  a  grain,  nitro-glycerine  in 
one-minim  doses  of  a  one  per  cent,  solution,  croton-chloral,  gel- 
semiam,  tonga,  antipyrin,  phenacetin  and  phosphorus,  may  suc- 
cessively be  given.  Locally,  the  part  may  be  painted  with  lini- 
ment of  aconite  or  rubbed  with  ointment  of  aconitine  ;  or  the 
actual  cautery,  or  small  blisters  applied  over  the  course  of  the 
nerve  ;  or  morphia  or  osmic  acid  injected  subcutaneously.  In 
simple  neuralgia  of  the  sciatic  nerve  the  continuous  current,  with 
the  positive  rheophore  applied  over  the  sacro-iUac  synchondrosis 
and  the  negative  in  a  vessel  of  salt  and  water  in  which  the  foot  is 
placed,  is  often  of  great  benefit.  Neurotomy,  or  dividing  the 
nerve,  and  neurectomy,  or  cutting  a  piece  out  of  the  nerve,  have 
long  been  practiced  for  obstinate  trigeminal  neuralgia,  but  are 
attended  with  but  veiy  temporary  benefit.  Nerve-stretching  holds 
out  better  prospects  of  success.  It  consists  in  cutting  down  upon 
the  nerve,  catching  it  up  with  a  blunt  hook  or  aneurysm  needle 
passed  beneath  it,  and  forcibly  stretching  both  the  proximal  and 
distal  ends.  The  strain  that  a  nerve  will  bear  vvithout  breaking 
of  course  varies  with  its  size,  but  it  is  very  considerable.  The 
sciatic  nerve,  which  is  sometimes  stretched  for  sciatica,  is  so 
strong  that  the  patient  can  be  lifted  up  from  the  table  by  it  with- 
out its  giving  way.  This  nerve,  however,  may  be  stretched  by 
what  is  called  the  bloodless  method — /.  e.,  by  extending  the  leg 
on  the  thigh,  and  forcibly  flexing  the  thigh  on  the  body.  The 
effect  upon  the  pain  produced  by  nerve-stretching  is  variously 
supposed  to  depend  on — i,  some  alteration  of  the  molecular  ele- 
ments of  the  nerve  which  may  be  transmitted  to  the  nerve  centres  ; 
2,  some  alteration  in  its  vascular  or  nervous  supply  ;  3,  the  break- 
ing clown  of  adhesions  which  may  have  formed  around  it.  This 
oi)eration  is  not  infrequently  practiced  for  intractable  trigeminal 
or  epileptiform  neuralgia.  The  relief  it  gives  is  unfortunately  not 
always  permanent,  though  considerable  periods  of  immunity  have 
been  gained,  and  after  the  return  of  the  pain  the  operation  may 
be  repeated.  At  any  rate  it  appears  to  give  more  lasting  relief 
than  either  neurotomy  or  neurectomy.  Cases  of  epileptiform 
neuralgia  that  have  resisted  all  other  treatment,  have,  in  several 
instances,  been  greatly  benefited,  if  not  cured,  by  the  excision  of 
Meckel's  ganglion.  In  others  the  trunk  of  the  fifth  nerve  or  all 
its  branches  simultaneously  have  been  divided,  and  the  Gasserian 
gangHon  has  even  been  removed.  These  very  severe  |)rocedures 
have  been  followed  by  sloughing  of  the  eye-ball.  Slight  injuries 
to  the  eye,  such  as  the  irritation  of  the  conjunctiva  by  the  anti- 
septic fluid  in  operations  upon  the  fifth  nerve,  and  especially  upon 
the  first  division,  may  lead  to  sujjpuration  of  the  globe.  It  has 
been  advised,  therefore,  to  sew  up  the  eyelids  previous  to  operat- 


NEURALGIA.  317 

ing.  Hypnotic  suggestion  has  been  much  practiced  abroad  for 
the  cure  of  neuralgia  and  allied  affections,  and  percussion  has 
given  relief. 

Methods  of  exposing  the  fifth  nerve  07-  its  branches  for  the  pur- 
pose of  neurotomy,  neurectomy,  or  stretching. — These  are  numer- 
ous.    A  brief  account  of  some  of  them  only  can  be  given. 

{a)  The  supra-orbital  branch  of  the  first  division  is  readily 
exposed  by  making  a  transverse  incision  through  the  tissues  over 
it  where  it  emerges  through  the  supra-orbital  notch,  which  can 
usually  be  felt  on  the  upper  margin  of  the  orbit. 

{b')  The  second  division  may  be  exposed — r,  where  it  emerges 
on  the  face,  through  the  infra-orbital  foramen,  or  2,  where  it 
leaves  the  skull  through  the  foramen  rotundum.  i.  To  expose 
the  nerve  where  it  emerges  on  the  face,  make  a  transverse  incision 
over  it  a  little  below  the  margin  of  the  orbit,  cutting  through  the 
skin,  orbicularis  ocuU  and  levator  labii  superioris.  If  there  is  any 
difficulty  in  finding  the  nerve,  pass  a  probe  into  the  infra-orbital 
foramen ;  this  will  serve  as  a  guide  to  it.  The  nerve  is  accom- 
panied by  the  infra-orbital  artery,  which,  if  divided,  should  be 
tied.  2.  To  expose  the  nerve  where  it  leaves  the  skull  through 
the  foramen  rotundum,  make  a  transverse  incision  about  a  quarter 
of  an  inch  below  the  margin  of  the  orbit,  and  from  the  center  of 
this  a  second  vertically  downwards  for  an  inch  and  a  half.  Carry 
the  incisions  to  the  bone  and  the  infra-orbital  nerve  will  be  ex- 
posed. Next  open  the  front  wall  of  the  antrum  with  a  trephine. 
Chip  away  with  small  curved  bone-forceps  the  lower  wall  of  the 
infra-orbital  canal,  the  nerve  will  then  be  exposed  as  far  as  the 
back  wall  of  the  antrum.  Perforate  this  wall  with  a  small  tre- 
phine and  enlarge  the  wound  with  bone-forceps  if  necessary;  the 
nerve  can  be  traced  across  the  spheno-maxillary  fossa  to  the  fora- 
men rotundum,  and  can  be  here  either  stretched  or  divided,  or 
a  portion  of  it  excised.  MeckePs  ganglion  can  now  be  re- 
moved, if  desired,  by  clearing  out  the  fat  in  which  it  lies  just 
below  the  nerve  in  the  spheno-maxillary  fossa.  The  deep  stage 
of  the  operation  will  be  facilitated  by  an  electric  lamp  or  mirror 
on  the  operator's  forehead.  I  have  stretched  this  nerve  and  re- 
moved the  ganglion  several  times,  and  much  prefer  the  method 
here  described  to  that  of  raising  the  periosteum  and  chipping 
away  the  upper  wall  of  the  canal.  1  am  of  opinion  that  the  in- 
flammation and  sloughing  of  the  globe  which  has  followed  opera- 
tion on  this  branch  of  the  fifth  are  dependent  in  a  greater 
measure  upon  the  disturbance  of  the  contents  of  the  orbit  than 
upon  the  interference  with  the  nerve.  No  inflammatory  mischief 
of  any  kind  has  followed  my  operations,  and  the  wounds  have 
healed  without  any  trouble. 


3X8  DISEASES   OF   SPECIAL   TISSUES. 

(c)  The  third  division,  or  its  inferior  dental,  gustatory,  or 
auriculo-temporal  branch  may  be  exposed  as  follows: — The 
inferior  dental  is  best  dealt  with  through  the  mouth.  I  have 
stretched  it  in  this  way  a  number  of  times,  and  can  speak  in  the 
highest  terms  of  the  method.  The  septic  troubles,  necroses,  etc., 
to  avoid  which  many  elaborate  operations  have  been  undertaken, 
are  in  my  experience  purely  mythical,  and  I  consider  such  opera- 
tions quite  unjustifiable.  Open  the  mouth  with  a  gag ;  make  an 
incision  through  the  mucous  membrane  from  the  last  molar  tooth 
in  the  upper  to  the  last  molar  in  the  lower  jaw.  Insert  the  finger 
between  the  internal  pterygoid  muscle  and  the  bone  ;  feel  for  the 
tongue  of  bone  at  the  entrance  of  the  interior  dental  foramen  ; 
pass  an  aneurysm  needle  having  a  very  short  curve  into  the  wound  ; 
hook  up  the  nerve  and  stretch  or  divide  it,  or  excise  a  portion  if 
desired.  The  wound  heals  in  a  few  days  without  any  trouble  ;  and 
the  patient  may  be  about  his  work  within  a  week.  The  gusiaio?y 
branch  may  be  stretched  through  the  same  incision  as  that  given 
above  ;  or  through  a  transverse  cut  made  in  the  mucous  mem- 
brane between  the  last  molar  tooth  and  side  of  the  tongue.  The 
auricu/o-teniporal  is  readily  reached  by  a  vertical  incision  over  the 
temporal  artery  extending  upwards  for  an  inch  and  a  half  from 
the  zygoma.  The  trunk  of  the  third  division  may  be  exposed  as 
follows  : — Make  a  curved  incision  from  the  root  of  the  pinna 
across  the  temporal  muscle  to  the  middle  of  the  malar  bone  ;  turn 
down  the  flap ;  divide  the  temporal  fascia ;  saw  through  the  zygo- 
matic arch  in  front  of  the  ear  and  through  the  middle  of  the  malar 
bone,  and  turn  down  the  zygoma  and  masseter  with  Stenson's  duct 
and  branches  of  the  facial  nerve.  Excise  the  coronoid  process 
with  the  lower  portion  of  the  temporal  muscle.  Draw  down  the 
external  pterygoid  till  the  foramen  ovale  is  exposed.  The  trunk 
of  the  third  division  may  here  be  stretched,  avulsed,  or  divided. 
Or  the  foramen  ovale  and  foramen  rotundum  may  be  laid  into 
one  by  bone-forceps  and  trephine,  and  the  trunks  of  both  the 
second  and  third  divisions  be  thus  attacked  intracranially.  The 
Gasserian  ganglion  may  at  this  stage  be  exposed  by  trephining 
the  great  wing  of  the  sphenoid  external  and  anterior  to  the  foramen> 
ovale,  laying  that  foramen  into  the  trephine  hole  by  cutting  away 
the  intermediate  bone  with  forceps,  and  raising  the  dura  with  an 
elevator.  The  posterior  part  of  the  ganglion  can  now  be  cut 
away  by  means  of  forceps,  sharp  spoons  and  curettes. 

Tumors  ok  nkrvks,  v/hatever  their  structure,  were  formerly 
called  neuromata.  This  term,  however,  should  be  restricted  to 
that  rare  form  of  tumor  composed  of  nerve  elements ;  whilst 
other  tumors  of  nerves  should  be  called  fibromata,  sarcomata,  etc., 
as  in  other  situations,  according  as  they  consist  of  fibrous  tissue, 
sarcoma  elements,  etc. 


PERFORATING  ULCER  OF  THE  ROOT. 


319 


Fig.  107. 


A  median  nerve, 
with  a  tumor  over 
which  the  fila- 
ments are  spread 
out.  St.  Barthol- 
omew's Hospital 
jNIuseum.) 


The  true  neuromata  are  exceedingly  rare,  and  call  for  no  fur- 
ther mention. 

The  fibromata,  though,  like  other  tumors  of  ner\-es,  far  from 
common,  are  the  variet}^  most  frequently  met 
with.  They  grow  from  the  connective  tissue, 
either  of  the  sheath,  or  its  prolongations  within 
the  nerve ;  in  the  latter  case  the  nerve-fibres  will 
be  spread  out  over  them  (Fig.  107).  They  are 
generally  single,  or  there  may  be  several  on  the 
same  or  on  different  nerves.  Signs. — They  occur 
as  painful,  more  or  less  globular  tumors  in  the 
course  of  a  nerve,  and  are  often  accompanied  by 
numbness,  tingling,  and  perhaps  muscular  spasm 
in  the  part  it  supplies.  They  can  be  swayed 
from  side  to  side,  but  cannot  be  moved  up  and 
down  in  the  long  axis  of  the  nerve.  Another 
form  of  fibrous  tumor  connected  with  nerves  is 
the  so-called  painful  subcutaneous  tumor  of 
Paget,  which  occurs  as  a  small  nodule  beneath 
the  skin,  and  causes  the  most  exquisite  pain  when 
handled.  The  treatment  consists  in  dissecting 
the  tumor  out,  or  if  this  is  impracticable,  remov- 
ing it  along  with  the  affected  portion  of  the  nerve,  and  then  sutur- 
ing the  divided  nerve-ends.  If  the  divided  ends  cannot  be 
brought  into  contact,  an  attempt  may  be  made  to  graft  a  piece  of 
nerve  between  them.  The  painful  subcutaneous  tubercle  is  readily 
removed  by  dissection. 

The  myxomata  are  the  next  most  common  tumors  of  nerv^es, 
and  give  rise  to  similar  symptoms. 

The  sarcomata,  though  more  rare,  may  also  be  met  with  in 
nerves,  and  are  sometimes  multiple. 

Convulsive  or  mu.scular  tic,  or  histrionic  spasm  as  it  is  some- 
times called,  is  a  convulsive  twitching  of  the  muscles  of  the  face, 
due  to  some  form  of  irritation  of  the  facial  nerve  the  nature  of 
which  is  not  known.  It  is  at  times  associated  with  neuralgia  of 
the  fifth  nerve.  Stretching  the  facial  nerve  just  after  it  emerges 
from  the  stylo-mastoid  foramen  may  be  undertaken  in  severe 
cases,  as,  for  instance,  where  the  spasm  interferes  with  sleep,  etc., 
and  with  a  fair  prospect  of  success. 

Perforating  ulcer  of  the  foot. — Though  the  pressure  of  a 
corn  can  generally  be  traced  as  the  exciting  cause  of  the  ulcer,  it 
would  appear  in  many  cases  to  depend  upon  changes  in  the 
peripheral  nerve?,  leading  to  trophic  changes  in  the  part  and  a 
consequent  lowered  resisting  power  of  the  tissues  to  injury  or 
pressure.     It  is  sometimes   associated  with  locomotor  ataxiaj  at 


320  DISEASES    OF   SPECIAL   TISSUES. 

times  with  diabetes,  and  mere  rarely  with  spina  bifida.  The  usual 
situation  of  the  ulcer  is  the  ball  of  the  great  or  little  toe.  It  is 
attended  with  but  slight  inflammation,  and  probing  causes  hardly 
any  pain.  It  may  lead  to  destruction  of  the  metatarso-phalangeal 
joint,  necrosis  of  the  bones,  and  perhaps  complete  perforation  of 
the  foot ;  it  is  sometimes  the  starting  point  of  gangrene.  There  is 
usually  local  sweating,  lowering  of  temperature,  and  impairment 
of  sensation  of  the  foot  and  lower  third  of  the  leg.  The  patella- 
reflex  is  often  lost.  Treatment. — Though  the  ulcer  will  often 
yield  to  prolonged  rest,  the  removal  of  dead  bone,  scraping,  tak- 
ing off  pressure  by  cutting  a  hole  in  a  thick  cork  sole,  and  other 
local  treatment,  amputation  is  sometimes  called  for.  Nerve- 
stretching  has  also  been  recommended.     Relapses  are  common. 

SURGICAL    DISEASES    OF    THE    SKIN. 

Verruce  or  WARTS,  are  small  excrescences  on  the  skin  formed 
by  the  hypertrophy  of  the  papillae  and  epidermis.  The  following 
varieties  are  described  :  t.  Verrucce  vulgares,  or  comm.on  warts, 
so  frequent  on  the  hands  of  children  and  young  adults.  2.  Ver- 
rucce seniles,  which  occur  as  brownish  elevations,  generally  about 
the  back,  neck  and  arms  of  old  people.  3.  VerruccR  necrogeniccc, 
common  on  the  hands  of  dissecting-room  porters  and  morbid 
anatomists.  4.  Venereal  tvarts,  met  with  on  the  genitals  as  the 
result  of  the  irritation  of  gonorrhoea  or  other  irritant  discharges. 
5.  Soot  warts,  which  affect  the  scrotum  of  chimney-sweeps,  and 
are  freqr.ently  the  starting  point  of  "sweep's  cancer."  6.  Con- 
genital warts,  which  take  more  the  form  of  irregularly-shaped 
growths  than  the  true  warts,  are  not  very  common.  Treatment. — 
Common  ivarts  often  disappear  spontaneously.  They  may  be 
readily  destroyed  by  such  caustics  as  salicylic,  acetic,  and  nitric 
acid,  or  nitrate  of  silver.  Venereal  warts  may  be  snipped  off  with 
the  knife  or  scissors.  Senile  warts,  when  large,  had  better  be 
excised.  The  soot  wart  ought  to  be  removed  at  once  by  the 
knife.  The  acid  nitrate  of  mercury  is  highly  spoken  of  as  an  ap- 
plication to  vejTJUOi  necrogeniccE. 

Clavus. — ('orns  consist  of  localized  thickenings  of  the  epider- 
mis, and  although  they  may  occur  on  any  part  of  the  body  that 
has  been  subjected  to  intermittent  pressure,  are  most  common  on 
the  feet,  where  they  are  produced  by  tight  or  badly- fitting  boots, 
especially  when  high  heels  have  been  worn,  and  the  weight  of  the 
body  has  tiuis  been  unnaturally  thrown  upon  the  toes  ;  they  are 
for  the  same  reason  frequently  met  with  in  talipes  cquinvis.  Two 
varieties  are  described,  the  hard,  occurring  on  exposed  parts. 
])articularly  the  dorsum  of  the  toes,  and  the  soft,  situated  between 


ONYCHIA.  321 

the  toes,  where,  in  addition  to  pressure,  the  parts  are  subjected  to 
moisture.  A  hard  corn,  on  section,  is  seen  to  be  more  or  less 
conical ;  and  it  is  the  pressure  of  the  apex  of  this  cone  upon  the 
papillary  layer  of  the  corium  that  causes  the  pain.  At  times  a 
bursa  is  developed  beneath  the  corn.  At  other  times  suppuration 
occurs,  and  the  pus  being  prevented  from  escaping  by  the  hard- 
ened cuticle,  gives  rise  to  great  tension,  pain  and  consequent 
inflammation  of  the  skin  and  -subcutaneous  tissue  around,  and 
may  even  terminate  in  ulceration,  which  may  extend  deeply  into 
the  foot.  Treatment. — A  hard  corn  should  be  pared  down,  and 
then  painted  night  and  morning  with  sahcylic  acid  and  collodion. 
In  the  meantime  all  pressure  should  be  removed  by  means  of  a 
corn-pad,  or  a  hollow  moulded  in  the  leather  of  the  boot.  Soft 
corns  should  be  allowed  to  become  dry  and  hard  by  separating 
the  toes  with  cotton-wool,  and  dusting  them  with  a  mixture  of 
oxide  of  zinc  and  iodoform,  or  ether  form  of  astringent  and  anti- 
septic powder,  and  then  treated  in  the  same  manner  as  hard 
corns.  Should  suppuration  occur  beneath  a  corn,  an  incision 
through  it  to  evacuate  the  pus  will  give  immediate  relief,  or  the 
corn  may  be  pared  down  with  a  sharp  scalpel,  till  the  pus  is 
reached,  without  giving  any  pain. 

Chilblains  are  local  congestions  of  the  skin  caused  by  exposure 
to  cold  and  damp  in  young  persons  with  a  feeble  circulation. 
They  commonly  occur  on  the  fingers  and  toes  ;  less  frequently  on 
the  nose  and  ears.  They  present  a  sharply-defined,  bluish-red 
blush  of  erythema,  disappearing  on  pressure,  and  slowly  return- 
ing. In  severe  cases  the  skin  becomes  dusky  and  purplish  in 
color,  and  the  cuticle  gives  way,  leaving  a  raw  surface  {^broken 
chilblains).  They  are  attended  with  intolerable  itching.  Treat- 
ment.— The  general  circulation  should  be  promoted  by  exercise 
and  good  food,  and  the  local  by  stimulating  hniments,  the  parts 
being  kept  warm  by  woolen  gloves  or  socks.  When  the  chilblain 
is  broken,  it  may  be  dusted  with  iodoform,  or  dressed  with  oxide 
of  zinc  or  soap-plaster.  Arsenic  internally  appears  sometimes  of 
service. 

Onychia,  or  onychia  maligna,  as  in  severe  cases  it  is  some- 
times called,  is  a  chronic  unhealthy  inflammation  of  the  matrix 
of  the  nail,  attended  with  ulceration  and  a  horribly  foetid  purulent 
discharge.  It  is  most  frequently  met  with  in  strumous  children 
as  the  result  of  a  crush  of  the  finger  or  some  slight  injury ;  but  it 
may  depend  on  syphilis,  or  more  rarely  on  eczema  or  psoriasis  of 
the  matrix,  or  its  inoculation  with  the  parasite  of  ringworm.  In 
a  typical  case  the  end  of  the  affected  finger  is  swollen  and  in- 
flamed and  of  a  dusky  or  livid  red  color,  whilst  the  nail  is 
blackened,  shrunken,  loosened  from  its  matrix,  surrounded  by  a 


32  2  DISE-\SES    OF    SPECIAL   TISSUES. 

crescent  of  unhealthy  ulceration,  and  bathed  in  a  very  foetid  dis- 
charge. It  is  exquisitely  tender  to  the  touch.  In  severe  cases 
the  ulceration  may  extend  to  the  bone  and  neighboring  joint,  and 
the  last  phalanx  be  lost.  Treatment. — The  nail,  if  black  and 
shriveled,  should  be  removed  by  forceps,  the  wound  powdered 
with  iodoform  or  nitrate  of  lead,  or  dressed  frequently  with  a 
lotion  of  liquor  arsenicalis  or  nitrate  of  silver.  In  strumous  sub- 
jects appropriate  constitutional  r'emedies  must  be  given.  If  there 
is  a  suspicion  of  constitutional  syphilis,  the  part  should  be  dusted 
with  calomel,  or  dressed  with  blackwash,  and  mercury  or  iodide 
of  potassium  given  internally.  In  some  inveterate  cases  it  may 
be  necessary  to  scrape  or  shave  away  the  matrix  of  the  nail,  or 
destroy  it  by  caustics. 

FuRUNCULUS,  or  BOIL. — A  boil  is  a  circumscribed  inflammation 
of  the  skin  and  subcutaneous  tissue,  terminating  in  gangrene  of 
the  central  part,  which  is  then  cast  off  in  the  form  of  a  slough, 
popularly  called  the  core.  Boils  generally  occur  in  crops,  one 
coming  out  after  the  other  has  healed  ;  or  several  small  boils  form 
around  a  larger  central  one.  They  are  usually  situated  on  the 
neck,  nates,  back  of  the  hand,  and  back.  Though  most  common 
in  the  young,  they  may  occur  at  all  ages.  The  causes  are 
numerous.  As  predisposing  may  be  mentioned  change  of  habit, 
a  too  exclusive  meat  diet,  diabetes,  albuminuria,  alterations  in 
the  blood  depending  on  acute  disease,  the  emanations  of  sewer 
gas,  change  of  season  or  air,  and  cachectic  conditions  however  in- 
duced. The  exciting  cause  is  any  local  irritation,  such  as  chafing 
of  the  neck  by  the  collar,  or  of  the  nates  in  rowing,  the  irritation 
of  morbid  fluids  in  making  post-mortem  examinations,  etc.  But 
frequently  no  efficient  cause,  either  constitutional  or  exciting,  can 
be  discovered.  The  staphylococcus  pyogenes  aureus,  which  is 
always  present  in  boils,  is  generally  thought  to  be  the  essential 
cause.  Signs. — A  boil  begins  as  a  red  pimple,  usually  with  a  hair 
in  the  centre,  and  as  it  increases  in  size  forms  a  painful,  dusky, 
purplish-red  and  conical  swelling,  with  a  flattened  apex.  The 
inflammation  may  at  times  subside,  and  the  boil  gradually  disap- 
pear {blind  boil^.  More  often  the  cuticle  separates  at  the  apex, 
a  vesicle  forms,  bursts,  and  leaves  a  yellow  slough  exposed,  which 
is  cast  off  as  a  central  core  through  a  single  opening.  Treattnent. 
— A  boil  may  sometimes  be  aborted  by  plucking  out  the  central 
hair,  injecting  with  carbolic  acid,  applying  nitrate  of  silver,  or 
painting  it  over  with  a  thick  layer  of  collodion.  Should  these 
fail,  a  linseed-meal  poultice  or  hot  fomentations,  and,  where  there 
is  much  pain,  glycerine  and  belladonna  may  be  applied,  and  after 
it  has  broken,  a  simple  healing  ointment.  An  incision  may  occa- 
sionally be  necessary.     The  constitutional   treatment  consists  in 


CARBUNCLE.  323 

attention  to  hygiene,  regulation  of  the  diet  and  secretions,  ad- 
ministration of  tonics,  etc.  Arsenic,  yeast  (gj.)  and  sulphide  of 
calcium  (gr.  li  to  Vz)  have  a;t  times  been  found  useful. 

Carbuncle  is  a  spreading  inflammation  of  the  subcutaneous 
tissue  involving,  to  some  extent,  the  overlying  skin  and  terminat- 
ing in  gangrene  of  the  affected  tissue,  which  is  discharged  in  the 
form  of  sloughs.  It  differs  from  a  boil  in  that  it  is  of  larger  size, 
has  a  tendency  to  spread,  and  is  flattened  instead  of  conical ; 
there  is  greater  brawniness  of  the  surrounding  tissues  ;  the  skin 
gives  way  at  several  places  instead  of  at  the  apex;  the  gangrenous 
tissue  is  discharged  in  the  form  of  sloughs  instead  of  as  a  core  ; 
and  it  is  accompanied  by  severe  constitutional  symptoms.  Cause. 
— Any  vitiated  state  of  the  constitution,  such  as  may  be  induced 
by  too  high  or  too  poor  living,  gout,  diabetes,  albuminuria, 
typhus  or  other  acute  fevers,  prolonged  lactation,  and  the  like. 
Friction  and  pressure  are  mentioned  as  exciting  causes,  and  are 
said  to  explain  the  frequency  of  its  occurrence  on  the  nape  of  the 
neck,  back,  and  nates.  The  presence  of  the  pyogenic  micrococci 
is  the  essential  cause.  It  is  more  common  in  men  than  in  women, 
and  does  not  usually  occur  till  after  the  middle  period  of  life. 
It  is  especially  dangerous  when  associated  with  diabetes,  and 
when  it  occurs  on  the  face  or  scalp.  In  the  former  situation, 
suppurative  phlebitis  of  the  angular  vein,  wnth  extension  of  the 
infective  thrombi  through  the  ophthalmic  vein  to  the  cavernous 
and  other  blood  sinuses  in  the  skull,  and  consequent  meningitis 
or  general  blood-poisoning,  is  the  danger  to  be  apprehended. 
Symptoms. — It  begins  as  a  hard  painful  swelling,  accompained  by 
fever,  generally  of  a  low  type  and  with  marked  depression.  The 
sweUing  rapidly  spreads,  and  forms  a  flattened,  generally  more  or 
less  circular,  elevation  of  the  skin,  surrounded  by  considerable 
brawny  induration  and  redness.  At  first  red,  it  soon  becomes 
purplish-red,  dusky  or  livid.  Vesicles  form  over  its  surface,  and 
on  bursting,  leave  a  number  of  apertures  in  the  skin  through  which 
a  greyish-yellow  slough  is  seen.  The  apertures  then  coalesce,  and 
the  slough  is  gradually  thrown  off,  leaving  a  granulating  wound  ; 
or  the  inflammation  continues  to  spread,  and  the  patient  may 
sink  into  a  low  typhoid  or  delirious  state  and  die  of  asthenia  or  of 
blood-poisoning  (saprjemia,  septicaemia,  or  pyaemia).  Treat- 
ment.— The  strength  must  be  supported  by  fluid  nourishment,  and 
stimulants  as  indicated  by  the  pulse  and  temperature  ;  the  patient 
should  have  abundance  of  fresh  air,  and  should  not,  if  it  can  be 
avoided,  keep  his  bed.  Opium  should  be  given  when  there  is 
much  pain.  Locally,  a  crucial  incision  was  formerly  a  favorite 
practice,  but  it  is  attended  with  so  much  haemorrage  that  unless 
the  patient's  powders  are  good  it  should  not  be  made.     Some  re- 


324  DISEASES   OF   SPECIAL  TISSUES. 

commend  the  introduction  of  potassa  fusa  or  the  injection  of  car- 
bohc  acid  into  the  carbuncle,  and  speak  highly  of  both  plans  as  a 
method  of  arresting  its  progress  while  still  small.  Others  apply 
strapping  firmly  over  it,  leaving  an  aperture  for  the  escape  of  the 
discharge  through  the  centre.  Others  again  make  a  subcutan- 
eous incision  when  there  is  much  pain  and  tension  ;  whilst  by  the 
majority  of  surgeons  the  expectant  treatment  of  merely  poulticing 
is  followed.  Poultices  are  open  to  the  objection  that  they  tend  to 
produce  putrefaction  of  the  sloughs,  and  as  their  chief  use  is  the 
application  of  heat  and  moisture,  a  better  substitute  is  some  hot 
antiseptic  lotion,  or  spongio-piline  steeped  in  hot  antiseptics. 
Scraping  away  the  sloughs  and  diseased  tissues  with  a  Volkmann's 
spoon  and  afterwards  swabbing  with  pure  carbolic  acid  is  recom- 
mended for  preventing  septic  poisoning.  I  have  tried  this 
method  and  can  speak  well  of  it.  The  hsemorrhage  attending  the 
scraping  is  much  less  than  might  be  imagined.  Healing  rapidly 
ensues.  When  the  sloughs  have  separated  or  have  been  removed, 
the  wound  should  be  treated  as  a  granulating  ulcer ;  but  as  it  is 
often  slow  in  healing  it  may  require  stimulation  with  resin  oint- 
ment, Peruvian  balsam,  etc. 

Lupus  Vulgaris  is  a  disease  of  childhood,  and  seldom  begins 
after  the  age  of  puberty.  It  is  characterized  by  the  formation  ot 
yellowish- red  nodules  in  the  skin  or  mucous  membrane,  and  sub- 
sequently by  scarring  and  often  great  destruction  of  the  affected 
tissues  and  much  deformity.  Cause. — It  is  generally  believed  to 
be  of  the  nature  of  a  local  tuberculosis  depending  on  the  pres- 
ence of  the  tubercle  bacillus.  Pathology. — The  deeper  layers  of 
the  corium  become  infiltrated  with  small  round  cells,  amongst 
which  new  capillaries  are  formed.  In  this  granulation-like  tissue 
are  found  non-vascular  areas  resembling  in  structure  miliary 
tubercles,  and  in  them  the  tubercle  bacillus  has  been  discovered. 
The  small-celled  infiltration  extends  along  the  vessels,  sweat- 
ghnds,  sebaceous  glands  and  hair-follicles,  and  may  finally  involve 
the  whole  of  the  corium.  The  granulation-like  tissue  may  then 
either  undergo  atrophy  and  be  partially  absorbed  without  ulcera- 
tion, though  leaving,  nevertheless,  a  permanent  scar ;  or  it  may 
undergo  caseation,  and  the  cuticle  giving  way,  break  down  into 
an  ulcer. 

Signs. — I'he  disease  begins  as  reddish  or  amber-colored,  semi- 
transparent,  jelly  like  nodules,  the  color  of  which  does  not  com- 
pletely disappear  on  pressure.  The  nodules  later  become  slightly 
elevated,  and  several  coalesce,  forming  l:uger  nodules  or  tubercles, 
over  which  the  cuticle  forms  slight  scales.  The  centre  of  the 
patch  may  now  undergo  atrophy  and  partial  absorption,  leaving 
a  slightly-depressed   whitish   cicatrix.     In   this  way  the  disease 


LUPUS   ERYTHEMATOSUS.  325 

may  become  cured  ;  or  while  cicatrization  is  taking  place  in  the 
centre  the  disease  may  continue  to  spread  at  the  margins.  Or 
the  lupus  patch  may  break  down  and  ulcerate,  the  surrounding 
skin  often  becoming  inflamed.  The  edges  of  the  ulcer  are  raised, 
whilst  its  base  is  smooth,  red,  and  spongy-looking.  The  ulcera- 
tion may  proceed  gradually  or  rapidly,  and  extend  through  the 
skin  or  mucous  membrane  to  the  underlying  structures,  destroy- 
ing, as  when  the  nose  is  attacked,  skin,  mucous  membrane, 
muscle,  cartilage,  in  fact  everything  except  bone.  The  favorite 
seat  of  lupus  vulgaris  is  the  face,  especially  the  ala  of  the  nose ; 
but  it  may  attack  the  skin  and  mucous  membrane  of  almost  any 
part.  It  is  more  common  in  females  than  in  males.  From 
tubercular  syphilis,  the  affection  for  which  it  is  perhaps  most 
likely  to  be  mistaken,  it  may  be  distinguished  by  the  age  at  which 
it  began,  the  history  of  the  case,  and  the  absence  of  concomitant 
signs  of  syphilis. 

Treatment. — The  lupus  patch  should  be  thoroughly  scraped 
with  a  Volkmann's  spoon,  the  scraping  being  continued  as  long  as 
any^soft  lupoid  material  comes  away,  and  until  the  tissues  feel 
hard  and  resisting  to  the  spoon.  The  actual  cautery,  or  some 
form  of  caustic,  is  then  by  some  applied  to  the  raw  surface,  but  it 
is  not  necessary.  The  wound  should  be  dressed  with  iodoform  or 
other  antiseptic,  and  healing  is  quickly  accomplished  with  com- 
paratively little  scarring.  Any  small  lupoid  tubercles  around  the 
main  patch  may  also  be  scraped  or  touched  with  the  galvano- 
cautery  point.  Internally,  cod-liver  oil,  arsenic,  or  the  phosphate 
or  the  iodide  of  iron,  may  generally  be  given  with  advantage. 

Lupus  erythemajosus  is  a  chronic  inflammation  of  the  seba- 
ceous follicles  and  surrounding  connective  tissue.  Pathology. — 
The  capillaries  of  the  follicles  become  dilated,  and  the  tissues 
infiltrated  with  small  round  cells.  The  follicles  then  become  en- 
larged and  distended  with  sebaceous  material,  which  exudes  and 
forms  greasy  scales  on  the  surface  of  the  lupus  patch.  The  scales, 
on  removal,  are  found  continuous  with  the  plugs  of  sebaceous 
material  filling  the  follicles.  Later,  the  follicles  are  destroyed, 
and  the  infiltrating  ceils  converted  into  cicatricial  fibrous  tissue. 
The  cause  is  unknown,  but  it  is  believed  to  depend  neither  on 
syphilis  nor  on  tubercle.  It  has  not  been  proved  to  be  hereditary, 
and  it  is  not  contagious.  Signs. — It  begins  most  commonly  on 
the  cheeks  or  nose,  in  the  form  of  one  or  more  erythema-like  red 
patches,  which  fade  momentarily  on  pressure,  and  are  often  at- 
tended with  itching.  The  patches  become  covered  with  greasy 
scales  continuous  with  the  sebaceous  matter  in  the  enlarged  folli- 
cles. They  usually  spread  by  their  slightly  raised  edges,  leaving 
dry,  pale,  depressed  scars  in  their  centre,  which  are   productive 


320  DISEASES   OF    SPECIAL   TJSSUES. 

of  considerable  deformity,  but  ulceration  does  not  occur.  The 
disease  is  nearly  always  symmetrical,  affects  most  commonly  the 
cheeks  and  nose,  less  commonly  the  ears,  lips,  backs  of  the  hands 
and  fingers,  and  after  an  apparent  cure  is  liable  to  a  relapse.  It 
is  most  frequent  in  women,  begins  in  young  adult  life,  is  very 
chronic  in  its  course,  and  is  often  complicated  by  attacks  of  ery- 
sipelas. Treatment. — The  general  health  should  be  attended  to, 
and  arsenic,  cod-liver  oil,  or  iron  should  be  given  if  indicated. 
Local  treatment,  however,  is  the  only  efficient  means.  Very 
numerous  applications  for  relieving  the  itching  and  promoting 
absorption  have  been  recommended,  such  as  mercurial  plaster, 
iodine,  and  oleate  of  zinc  ;  but  the  best  method  is  linear  scarifi- 
cation, which  must  be  repeated  from  time  to  time  for  consider- 
able periods. 

Ingrowing  nail  is  most  frequently  met  with  in  the  great  toe  as 
the  result  of  wearing  tight  boots  and  of  cutting  the  nails  square. 
The  tight  boot  presses  the  skin  over  the  sharp  corner  of  the  nail 
on  each  side,  and  ulceration,  attended  by  the  formation  of  ex- 
quisitely tender  and  exuberant  granulations,  results,  giving  the 
part  the  appearance  as  if  the  nail  had  grown  into  the  flesh.  The 
condition  is  a  very  painful  one,  and  troublesome  to  cure.  The 
treatment  consists  in  wearing  square-toed  boots,  so  as  to  provide 
plenty  of  room  for  the  toes,  and  then  pressing  a  piece  of  tinfoil 
or  lint  between  the  edge  of  the  "ingrowing"  nail  and  the  over- 
hanging portion  of  skin.  Should  this  not  succeed,  a  longitudinal 
strip  of  nail  should  be  removed,  and  the  prominent  granulations 
and  redundant  skin  shaved  away  to  the  level  of  the  nail,  together 
with  that  portion  of  the  matrix  corresponding  to  the  strip  of  nail 
removed.  As  the  operation  is  excessively  painful,  it  should  be 
done  under  an  anaesthetic  (gas  is  sufficient),  or  the  ether  spray 
may  be  used,  or  the  part  injected  with  cocaine. 

Hypertrophy  of  the  toe-nail  occasionally  occurs  as  the  result 
'of  neglect  or  chronic  congestion  of  the  matrix,  and  may  assume 
the  form  of  a  horn.  The  treatment  consists  in  cutting  away  the 
hypertrophied  portion,  or  in  removing  the  whole  nail. 


INJURIES    OF    THE    HEAD. 


327 


SECTION  V. 


INJURIES  OF  REGIONS. 


INJURIES   OF    THE    HEAD. 


Fig.  108. 


cephalhjema- 
a  depressed 
dark  shading 


Injuries  of  the  Scalp. 

Contusions  of  the  scalp  are  very  common  as  the  result  of  falls 
or  blows  on  the  head,  and  are  frequently  followed,  especially  in 
children,  by  extravasation  of  blood,  and  the  consequent  formation 
of  a  hcBmatoma  or  blood-tumor.  In  new-born  infants  such 
tumors  are  of  frequent  occurrence  in  consequence  of  severe  pres- 
sure on  the  head  during  birth,  especially  when  instruments  have 
been  used,  and  are  then  known  as  cepJial- 
hcematomata .  The-  blood  may  be  ex- 
travasated  ( i )  between  the  aponeurosis 
and  the  pericranium  :  and  (2)  between 
the  pericranium  and  the  bone.  In  the 
latter  situation  the  resulting  tumor  is 
generally  circumscribed  in  consequence 
of  the  pericranium  being  firmly  attached 
along  the  lines  of  the  sutures;  in  the 
former  it  is  generally  diffuse,  and  in 
some  instances  extends  over  the  whole 
of  one  side  of  the  head.  The  diffuse  form  can  only  be  mistaken 
for  an  abscess,  from  which,  however,  it  may  be  distinguished  by 
its  sudden  formation  and  the  absence  of  signs  of  inflammation. 
The  circumscribed,  which  gives  rise  to  a  soft  fluctuating  tumor 
with  hard  and  often  sharp  margins,  is  sometimes  very  difficult  to 
diagnose  from  a  depressed  fracture.  In  the  case  of  the  blood- 
tumor  the  hard  margins  (which  are  due  to  the  coagulation  of  the 
blood  at  the  circumference — the  central  part  remaining  fluid)  are 
raised  above  the  level  of  the  surrounding  bone,  as  may  be  de- 
tected by  passing  the  finger  along  the  scalp  ;  while  on  pressing 
upon  them  with  the  finger-nail  the  blood  may  be  displaced  and 
the  bone  be  felt  beneath.  As  a  rule,  the  blood  becomes  absorbed, 
but  ossification  at  times  occurs  in  the  angle  where  the  pericranium 
is  raised  from  the  bone.  Treattrient. — Under  the  use  of  evapo- 
rating lotions  the  more  superficial  h^ematomata  will  usually  subside. 
It  may  sometimes  be  necessary,  however,  to  aspirate  those  more 


Section   of   a 
toma;     and     B 
fracture.      The 
in  A.  represents  the  coagulated 
blood. 


328  INJURIES   OF    REGIONS. 

deeply  situated.  If  suppuration  occurs  a  free  incision  should  be 
made. 

Wounds  of  the  scalp  vary  in  extent  from  a  mere  scratch  to  an 
extensive  denudation  of  the  bone,  and,  like  other  wounds,  may 
be  incised,  lacerated,  punctured,  or  contused.  Though  large  por- 
tions of  the  scalp  may  be  torn  up  from  the  bone,  sloughing  is  very 
rare,  as  the  arteries  which  supply  the  scalp  run  between  the  skin 
and  the  aponeurosis,  and  hence  are  contained  in  the  flap.  Scalp- 
wounds  are  frequently  attended  with  sharp  hcemorrhage  ;  they 
are  also  often  associated  with  fracture  of  the  skull,  search  for 
which  should  always  be  made  by  passing  the  finger  into  the 
wound.  Moreover,  they  are  apt  to  be  complicated  by  erysipelas 
or  cellulitis,  with  the  formation  of  pus  between  the  aponeurosis 
and  the  pericranium,  and  where  the  bone  has  been  much  contused, 
by  suppuration  beneath  the  pericranium,  in  the  diploe,  or  be- 
tween the  bone  and  dura  mater.  Suppuration  in  any  of  these 
three  situations  may  be  followed  by  necrosis  of  the  bone,  by  sep- 
ticaemia or  pyaemia,  or  by  inflammation  of  the  brain  and  its  mem- 
branes. When  a  flap  of  the  scalp  has  been  completely  detached, 
and  even  when  the  pericranium  has  also  been  lost,  necrosis  need 
not  necessarily  occur,  since  granulations  may  spring  up  from  the 
bone,  and  cicatrization  follow. 

Treatment. — The  scalp  should  be  shaved  for  some  distance 
around  the  wound,  well  washed  with  soap  and  water,  then  with 
ether  or  turpentine,  and  finally  with  an  antiseptic,  whilst  the 
wound  should  be  carefully  cleansed  from  all  loose  hairs,  dirt,  grit, 
etc.,  then  flushed  out  with  the  antiseptic,  and,  if  small  and  in- 
cised, closed  with  adhesive  strapping  over  a  pad  of  sal  alembroth 
gauze  and  supported  by  a  capeline  or  other  form  of  bandage. 
When  large  portions  of  the  scalp  have  been  stripped  up  but  not 
detached,  the  flaps  after  cleansing  should  be  carefully  replaced, 
and  secured  by  aseptic  sutures.  Hasmorrhage  is  usually  readily 
controlled  by  pressure,  though  occasionally  it  may  be  necessary 
to  completely  divide  a  partially  torn  artery  or  to  apply  a  ligature. 
If  the  wound  is  extensive  the  scalp  should  be  completely  shaved 
and  cleansed  as  above  mentioned,  whilst  the  patient  shouUl  be  kept 
at  rest  for  a  few  days,  placed  on  low  diet,  a  smart  ])urge  given,  and 
a  careful  watch  made  for  signs  of  sujjpuration.  ShouUl  such  oc- 
cur, the  adhering  margins  of  the  wound  should  be  separated  to  per- 
mit the  free  escape  of  the  pus,  and  the  wound  be  allowed  to  heal 
by  granulations.  If  pus  forms  at  some  distance  from  the  wound, 
an  incision  must  be  made  at  that  spot  through  the  scalp,  of  course 
avoifling  the  track  of  any  large  vessel. 


FRACTURES  OF  THE  VAULT.  329 

Injuries  of  the  Cranial  Bones. 

Contusions  of  the  cranial  bones  are  always  serious,  espe- 
cially when  attended  with  a  wound  of  the  scalp,  inasmuch  as  they 
are  liable  to  be  followed  by — i.  Inflammation  of  the  pericranium, 
which  may  terminate  in  suppuration  between  it  and  the  bone  and 
necrosis  of  the  external  table  or  even  of  the  whole  thickness  of 
the  skull ;  2.  Suppuration  in  the  diploe,  with  implication  of  the 
large  diploic  veins,  and  probably  septicaemia  or  pyaemia ;  3.  Sup- 
puration between  the  bone  and  dura  mater,  and  subsequent  gen- 
eral meningitis  ;  4.  Chronic  inflam.matory  thickening  of  the  cranial 
bones  or  dura  mater,  giving  rise  to  constant  headache,  impair- 
ment of  one  of  the  special  senses,  epilepsy,  or  even  insanity  ;  and 
5.  Cerebral  abscess. 

Signs. — ^^Contusions  of  the  skull  are  attended  by  no  primary 
symptoms,  but  should  any  of  the  above-mentioned  conditions 
supervene  there  will  be  the  usual  signs  of  inflammation  localized 
to  the  injured  spot,  with  more  or  less  constitutional  disturbance. 
I.  In  simple  pericranial  inflammation  the  symptoms  will  usually 
subside  in  a  few  days.  2.  Should  pus  form  between  the  peri- 
cranium and  the  bone,  there  may  be  chills,  and  perhaps  rigors, 
with  local  signs  of  suppuration  ;  whilst  the  bone,  should  necrosis 
occur,  will  become  dry  and  yellowish-brown  or  greenish-white  in 
color.  3.  Should  suppuration  ensue  in  the  diploe,  there  will  be 
rigors,  followed  by  high  temperature,  and  probably  later,  signs  of 
pyaemia  or  septicaemia.  4.  Pus  between  the  bone  and  dura  mater 
will  be  indicated  by  headache,  vomiting,  rigors,  monoplegia  or 
hemiplegia,  delirium,  or  stupor,  followed  by  convulsions  or  coma 
(see  ijitracranial  suppuration)  ;  whilst  locally  a  circumscribed 
swelling  may  form  over  the  injured  spot  {Pott's puffy  tumor),  or 
if  there  be  a  wound  it  will  become  dry  and  the  bone  discolored. 

Treatment. — When,  from  the  account  of  the  injury,  it  is  prob- 
able that  the  bone  has  been  contused,  measures  should  be  taken 
to  prevent  inflammation  by  rest,  cold  to  the  head,  free  purging, 
and,  where  there  is  a  wound,  by  strict  antiseptic  precautions. 
Should  suppuration  be  suspected  between  the  pericranium  and 
the  bone,  free  incisions  to  let  out  the  pus  should  at  once  be  made  ; 
whilst  should  the  signs  point  to  the  formation  of  pus  between  the 
bone  and  dura  mater,  the  trephine  should  be  applied.  For  sup- 
puration in  the  diploe.  and  the  consequent  septicaemia  and 
pyaemia,  little  or  nothing  can  be  done. 

Fractures  of  the  bones  of  the  skull  may  be  divided  into — 
I.  Fractures  of  the  vault ;  and  2.  Fractures  of  the  base. 

I.  Fractures  of  the  vault. —  Causes.  —  Generally  direct 
violence,  as  a  blow  on  the  head  with  a  sharp-pointed  body,  or  fall 
14* 


330  INJURIES    OF    REGIONS. 

on  a  sharp  edge.  (Blows  with  soft  bodies  or  falls  on  soft  ground 
on  the  head  more  often  cause  a  fracture  of  the  base,  or  a  fissured 
fracture  extending  over  the  vault  to  the  base.)  Occasionally  in- 
direct violence,  as  a  blow,  say  on  the  front  of  the  head,  causing  a 
fracture  at  the  back  {fracture  by  contrecoup). 

Varieties. — The  fracture  may  take  the  form  of  a  simple  fissure 
{fissured  fracture),  or  of  several  fissures  radiating  in  various  di- 
rections {stellate  or  radiated  fracture)  ;  or  the  skull  at  the  seat  of 
injury  may  be  broken  into  several  pieces  {comminuted  fracture) , 
one  or  more  of  which  may  be  pressed  inwards  below  the  surface 
of  the  rest  of  the  bone  {depressed fracture)  ;  or  a  portion  of  bone 
in  rare  instances,  as  in  some  forms  of  sabre-wounds,  may  be 
raised  above  the  surface  of  the  skull  {elevated  fracture).  At 
times  the  fracture  consists  of  a  mere  puncture  of  the  bone,  with 
driving  inwards  into  the  membranes  or  brain  of  the  sharp  frag- 
ments of  the  inner  table  {punctured  fracture)  ;  and,  lastly,  the 
fracture  may  be  limited  either  to  the  outer  or  to  the  inner  table 
of  the  skull  {partial fracture).  In  any  of  these  varieties,  except, 
perhaps,  in  the  punctured,  the  scalp  may  remain  whole,  when  the 
fracture,  as  in  other  situations,  is  said  to  be  simple ;  or  there  may 
be  a  wound  of  the  scalp  leading  to  the  fracture,  when  it  is  said  to 
be  compound.  In  children  the  bone  may  be  depressed  without 
fracture. 

State  of  the  parts. — In  simple  fissure  there  is  no  displacement 
of  the  bone,  but  a  mere  crack  extending  from  the  part  struck  for 


Fig.  log. 


■   I 

i 


pro  .i/.-n ■;■■■■.■  ■■  .  C;,'  .     ■  .', .. .  ■:;:  -'^^V 


Depressed  fracture  (ponrt  variety).  Elevated  fracture,  probably  from  the  cut  of  a 

(St.      Bartholomew's      Hospital  sabre.     (St.  Bartholomew's  Hospital   Mu- 

Sluseum.)  scum.) 

a  variable  distance  over  the  vault,  and  frequently  running  through 
the  base  of  the  skull.  In  the  stellate  fracture  several  fissures 
radiate  over  the  vault  from  a  certain  point,  at  which  the  bone  is 
fref|uently  punctured.  The  comminuted  fracture  is  '  generally 
compotmd,  anrl  one  or  more  of  the  fragments  may  be  completely 


FRACrURES  OF  THE  VAULT. 


331 


detached  or  driven  through  the  dura  mater  into  the  brain,  which 
itself  may  protrude  through  the  external  wound.  In  the  depressed 
fracture  the  depressed  fragments  may  be  loose,  or  firmly  locked 
together,  often  forming  a  shallow  or  deep  rounded  or  oval  depres- 
sion,— pond  and  gutter  fractures,  as  they  are  sometimes  called 
(Fig.  109).  Ek coated  fractures  (Fig.  no)  are  not  often  met 
with  in  civil  practice.  They  are  the  result  of  oblique  cuts,  as  by 
a  sabre,  and  only  occur  in  young  adults  whilst  the  bone  is  com- 
paratively soft.  In  punctured  fractures  (Fig.  in),  which  are 
generally  produced  by  a  blow  with  a  sharp  instrument,  as  a  pick- 
axe or  a  fragment  of  a  falling  chimney-pot,  or  by  a  fall  on  a  spike, 
etc.,  the  splinters  of  the  internal  table  are  often  driven  into  the 
dura  mater  or  brain  at  right  angles  to  the  rest  of  the  bone.  When 
the  membranes  are  not  injured  at  the  time  of  the  accident,  the 
irritation  of  these  sharp  fragments,  if  not  removed,  is  nearly  cer 
tain  to  set  up  meningitis.  At  times  the  inflicting  body  has  been 
found  broken  off  flush  with  the  surface  of  the  skull.  Fracture  of 
the  external  tabic  alone  is  most  common  over  the  frontal  sinuses, 
where  it  is  separated  for  some  distance  from  the  internal.     In 


Fig.  III. 


Fig. 


Punctured  fracture.     fSt.  Barthol- 
omew's Hospital  Museum.) 


Fracture  of  the  internal  table.     iDruitt's 
Surgery.) 


fracture  of  the  internal  tad/e  (Fig.  11 2),  which  is  a  rare  accident, 
there  may  be  merely  a  splintering  of  the  bone,  or  a  fragment  may 
be  completely  detached  or  driven  into  the  dura  mater  or  brain. 
Any  of  these  fractures  may  be  complicated  by  laceration  or  other 
injury  of  the  brain  or  its  membranes,  or  by  rupture  of  the  middle 
meningeal  artery  or  one  of  the  venous  sinuses.  In  all  fractures 
involving  both  tables,  except  in  the  simple  fissure,  there  is  usu- 
ally greater  splintering  of  the  internal  than  of  the  external  table. 
In  fractures,  however,  produced  from  within  the  cranium,  as  by  a 
bullet  passing  through  the  skull,  the  external  table  at  the  aperture 
of  exit  is  more  splintered  than  the  internal.     The  reason  for  the 


332  INJURIES   OF   REGIONS. 

greater  splintering  of  the  internal  table  (or  the  external  table 
when  fractured  from  within)  is,  that  the  force  is  broken  in  per- 
forating the  external  table,  and  becomes  more  distributed  over  the 
internal.  It  was  formerly  said  to  be  due  to  the  internal  table  be- 
ing more  brittle  than  the  external. 

Signs. — Whatever  the  form  of  fracture,  it  may  be  accompanied 
by  signs  of  concussion,  compression,  or  other  injury  of  the  brain. 
Here  only  are  given  the  principal  local  signs  of  the  various  forms 
of  fracture  of  the  vault.  In  a  simple  fissured  fract:i)-e  there  is  no 
sign,  but  in  the  compoiind  variety  the  fissure  may  be  detected  by 
the  finger  in  the  wound.  A  sharp  edge  of  the  torn  pericranium,  a 
suture,  or  a  natural  inequahty,  may,  however,  if  care  is  not  exer- 
cised, be  mistaken  for  such  a  fissure.  In  the  depressed  fracture, 
the  depression  in  the  bone  in  the  simple  variety  may  be  obscured 
by  extravasated  blood  either  in  the  scalp  or  under  the  pericranium, 
but  in  the  compound  \3.x\tty  it  can  be  felt  by  the  finger  and,  if  the 
wound  is  large,  seen.  In  both  varieties,  when  the  bone  is  much 
depressed,  signs  of  local  compression  of  the  brain  may  be  present. 
In  iht  punctured  fracture  the  sharp  fragments  maybe  detected, 
with  the  finger  or  with  a  probe,  projecting  into  the  interior  of  the 
cranium,  and  signs  of  local  compression  may  or  may  not  be  pres- 
ent ;  later,  symptoms  of  inflammation  of  the  brain,  if  the  frag- 
ments are  not  removed,  w-ill  almost  certainly  supervene.  In  both 
the  compound  depressed  and  punctured  fracture  there  may  be 
comminution  or  loss  of  bone,  and  portions  of  lacerated  brain 
substance  may  at  times  exude  through  the  fracture.  Fractuix  of 
the  inner  tabic  is  very  difficult  to  dingnose,  but  later  it  may  be 
indicated  by  an  increase  of  local  temperature,  signs  of  local  com- 
pression, and  localized  pain  from  irritation  of  the  dura  mater.  It 
is  said  that  a  friction  sound  may  sometimes  be  heard,  from  the 
nibbing  of  the  brain  and  pia  mater  on  the  sharp  fragments. 
When  a  fracture  is  situated  over  the  frontal  sinuses  there  may  be 
emphysema  from  escape  of  air  into  the  connective  tissue,  or  if  the 
fracture  is  compound  air  may  be  forced  out  of  the  wound  on  blow- 
ing the  nose. 

The  treatment  of  fracture  of  the  vault  will  necessarily  vary  accor- 
ding to  the  nature  of  the  fracture  and  of  any  cerebral  complica- 
tions that  may  be  present.  The  general  indications  are  to  prevent 
inflammation  of  the  brain  and  its  membranes,  and  to  relieve  any 
existing  brain  complication.  Thus  the  patient  should  be  placed 
at  perfect  rest  in  a  darkened  room,  every  source  of  cerebral  irri- 
tation avoided,  an  ice-bag  api)lied  to  the  shaven  head,  the  bowels 
acted  on  by  a  calomel  purge,  and  the  i,diet  restricted  to  slops. 
When  the  fracture  is  compound  every  care  should  be  taken  to 
render  the  wound  aseptic,  and  to  promote  healing  by  the  first  in- 


FRACTURE    OF   THE    BASE.  333 

tention.  i.  In ^ssu fed  iracime  uncomplicated  by  cerebral  mis- 
chief little  more  will  be  required ;  but  when  symptoms  of  cer- 
ebral compression  are  present  the  question  of  trephining  may  be 
raised,  and  will  turn  upon  the  probable  nature  of  the  cerebral 
lesion  (see  Compression  of  the  Brain).  2.  In  depressed  fracture 
the  treatment  will  differ  according  as  the  fracture  is  simple  or  com- 
pound, and  according  as  symptoms  of  local  compression  of  the 
brain  are  or  are  not  present.  In  the  simple  form,  unless  the  de- 
pression is  deep  and  there  are  signs  of  local  compression,  no 
operative  interference  should  be  undertaken.  In  the  compound 
form,  any  fragment  found  loose  or  penetrating  the  membranes  of 
the  brain  should  be  removed,  or  if  slightly  depressed,  raised,  pro- 
vided the  elevator  can  be  readily  inserted  beneath  it.  If  a  frag- 
ment is  deeply  depressed  and  cannot  be  raised  by  the  elevator, 
the  trephine  had  better  be  applied.  When,  however,  the  depres- 
sion is  but  slight,  and  the  fragments  are  interlocked,  as  m  pond 
and  gutter  fractures,  the  case,  unless  there  are  signs  of  local  com- 
pression of  the  brain,  should,  as  a  rule,  be  left  to  nature.  The 
patient,  however,  should  be  carefully  watched  lest  inflammation 
supervene,  on  the  first  signs  of  which  the  depressed  bone  should 
be  removed  by  the  aid  of  the  trephine.  In  both  the  simple  and 
compound  varieties  the  depressed  bone,  if  it  is  apparendy  causing 
compression  of  the  brain,  must  be  raised  by  the  elevator,  or  by 
means  of  the  trephine. 

It  may  here  be  remarked  that  some  Surgeons  recommend  the 
raising  of  the  depressed  fragments  under  nearly  all  circumstances, 
even  when  there  is  no  external  wound ;  as  although  many  cases 
of  depressed  fracture  undoubtedly  recover,  nevertheless,  inflam- 
mation of  the  brain  and  its  membranes,  or  if  this  danger  is 
escaped,  subsequent  trouble,  such  as  long-continued  headache, 
progressive  mental  inability,  or  even  epilepsy  and  insanity,  may 
ensue  from  the  irritation  of  the  depressed  bone.  In  punctured 
fracture  the  trephine  should  always  be  applied,  as  here  the  frag- 
ments are  driven  vertically  inwards  (see  Fig.  m),  and  though 
they  may  not  have  punctured  the  dura  mater,  will  invariably  set 
up  inflammation  if  not  removed.  In  fracture  of  the  internal  table, 
too,  the  trephine  ought  to  be  applied  ;  but  this  form  of  fracture  is 
seldom  diagnosed. 

After  any  kind  of  fracture  the  patient  should  be  carefully 
watched  for  a  month  or  six  weeks,  and  even  though  no  comphca- 
tions  are  present  as  first,  the  greatest  care  should  be  exercised, 
and  any  indiscretion  in  diet,  abuse  of  stimulants,  or  undue  mental 
excitement,  should  be  avoided. 

2.  Fracture  of  the  base  is  generally  caused  by  a  blow  or  fall 
upon  the  vault,  the  fissure  extending  from  the  part  struck  to  the 


334  INJURIES    OF    REGIONS. 

base  ;  or  it  may  be  due  to  a  fall  upon  the  feet  or  nates,  the  frac- 
ture being  then  produced  by  the  shock  transmitted  to  the  occipi- 
tal bone  through  the  spine.  Rarely  it  has  been  caused  by  a  sharp 
instrument,  as  a  sword  thrust  through  the  roof  of  the  orbit  or  nose, 
or  by  a  blow  on  the  lower  jaw  fracturing  the  glenoid  cavity  or 
forcing  the  condyle  through  it.  As  a  rule  the  anterior,  middle  or 
posterior  fossa  is  found  fractured,  according  as  the  blow  falls  upon 
the  anterior,  middle,  or  posterior  part  of  the  vault  of  the  skull. 
Should  the  force,  however,  be  very  severe,  fissures  may  radiate 
from  the  seat  of  injury  to  two,  or  even  to  all  three  fossa;.  Frac- 
tures through  the  middle  fossa  generally  involve  the  petrous  por- 
tion of  the  temporal  bone  on  one  or  both  sides  of  the  skull.  Thus 
they  frequently  extend  through  the  internal  and  external  auditory 
meatus  and  walls  of  the  tympanum,  lacerating  the  prolongation  of 
dura  mater  contained  in  the  internal  auditory  meatus,  the  reflex- 
ion of  the  arachnoid  around  the  seventh  pair  of  nerves,  and  the 
membrana  tympani,  and  so  allow  of  the  escape  of  the  cerebro- 
spinal fluid  from  the  external  auditory  meatus.  The  fracture  may 
also  involve  the  lateral  sinus  or  middle  meningeal  artery,  in  which 
case  blood  may  be  found  mixed  with  the  cerebro-spinal  fluid  that 
escapes  from  the  ear.  Fracture  of  the  posterior  fossa  extends 
through  the  foramen  magnum  of  the  occipital  bone,  and  frequently 
through  the  petrous  portions  of  the  temporal  bones.  Fracture  of 
the  anterior  fossa  involves  the  roof  of  the  orbit  and  nose.  One  or 
more  of  the  nerves  that  escape  through  the  bony  foramina  in  the 
base  of  the  skull,  the  lateral  sinus,  the  middle  meningeal  artery, 
or  one  of  the  smaller  blood-channels  are  frequently  torn  or  other- 
wise injured  in  a  fracture  of  the  base  ;  whilst  the  inferior  lobes  of 
the  brain  are  often  extensively  lacerated  and  contused,  or  com- 
pressed by  extra vasated  blood.  It  should  be  remembered  that  a 
fracture  of  the  base,  if  the  membrana  tympani  or  the  mucous 
membrane  covering  the  cribriform  plate  of  the  ethmoid  bones  is 
ruptured,  is  really  of  the  nature  of  a  compound  fracture,  and 
hence  is  liable  to  be  followed  by  septic  inflammation,  which, 
moreover,  may  spread  to  the  membranes  and  brain. 

Signs. — At  times  there  may  be  none,  and  the  nature  of  the  in- 
jury may  be  quite  overlooked.  Generally,  however,  symptoms, 
such  as  compression,  indicative  of  a  severe  lesion  of  the  brain,  co- 
exist, and  these,  together  with  the  history  of  the  way  in  which  the 
injury  occurred,  should  lead  us  to  suspect  that  the  base  is  frac- 
tured. The  signs,  however,  which  when  present  may  be  consid- 
ered diagnostic  of  the  injury  are — i.  The  escape  of  cerebro-spinal 
fluid  from  the  ear,  nose,  or  mouth,  or  from  a  wound  if  one  exists. 
2.  The  escape  of  blood  from  similar  situations.  3.  Effusion  of 
blood  under  the  conjunctiva,  about  the  mastoid  process,  or  in  the 


FRACTURE    OF    THE    BASE.  335 

sub-occipital  region ;  and  4.  Injury  of  one  or  more  of  the  cranial 
nerves. 

1.  Cerebro-spinal  fluid  consists  principally  of  water  holding  in 
solution  a  large  amount  of  chloride  of  sodium.  It  has  a  low 
specific  gravity  (1002),  and  contains  little  or  no  albumen,  but 
sometimes  a  trace  of  sugar.  When  it  escapes  in  considerable 
quantities  (several  pints  in  the  twenty-four  hours)  immediately 
after  an  injury,  it  is  pathognomonic  of  fracture  of  the  base.  Es- 
caping from  the  ear,  it  indicates  fracture  of  the  middle  or  posterior 
fossa  ;  from  the  nose  or  mouth,  generally  the  anterior  fossa,  though 
in  fracture  of  the  middle  or  posterior  fossa  it  may,  by  passing 
along  the  Eustachian  tube,  or  through  a  fracture  of  the  basilar 
process  with  laceration  of  the  mucous  membrane  of  the  pharyn- 
geal vault,  also  come  from  the  nose  or  mouth. 

2.  Blood  may  escape  from  the  same  parts  and  by  the  same 
channels,  but  has  not  the  like  diagnostic  value,  since  bleeding 
from  the  ear,  and  especially  from  the  nose,  may  occur  from  causes 
other  than  fracture.  Still  when  blood  escapes  in  considerable 
quantities,  and  for  some  time  after  the  injury,  it  is  when  combined 
with  other  evidence  of  severe  cerebral  mischief  a  sign  of  import- 
ance. It  should  not  be  forgotten  that  blood  coming  from  the 
nose  or  roof  of  the  pharynx  may  be  swallowed  and  afterwards 
vomited  or  passed  per  rectum. 

3.  Effusion  of  blood  under  the  ocular  conjunctiva,  and  ecchy- 
mosis  about  the  mastoid  process  and  sub-occipital  region,  are 
signs  of  less  value ;  the  former  may  indicate  fracture  of  the  ante- 
rior, and  the  latter  fracture  of  the  posterior  fossa,  the  blood  pass- 
ing along  the  floor  of  the  orbit  in  the  one  case  to  the  conjunctiva, 
and  in  the  other  draining  through  the  fracture  and  appearing 
under  the  skin. 

4.  Injury  to  one  or  more  of  the  cranial  ner\'es  will  be  indicated 
by  paralysis,  loss  of  function,  or  spasm  of  the  parts  which  they 
supply.  Thus  there  may  be  dropping  of  the  upper  eyelid  {pfosis) , 
external  squint,  loss  of  accommodation,  double  vision  {diplopia) , 
and  dilatation  of  the  pupil,  when  the  third  nerve  is  affected  ;  spasm 
or  paralysis  of  the  facial  muscles  {BelVs  paralysis'),  deafness  or 
loss  of  sight  if  the  facial,  auditory  or  optic  is  injured,  etc.,  but  as 
the  patient  is  frequently  comatose  these  signs  may  not  afford  much 
information.  The  paralysis  when  the  facial  nerve  is  affected  may 
come  on  immediately  after  the  accident  or  not  for  some  days.  In 
the  latter  case  it  is  due  to  inflammatory  effusion  about  the  nerve 
as  it  passes  through  the  aqueduct  of  Fallopius  over  the  tympanum. 

The  prognosis  is  always  grave,  the  lesion  generally,  though  not 
invariably,  terminating  fatally  from  concomitant  injury  to  the  brain, 
or  from  septic  inflammation  of  the  brain  and  its  membranes. 


336  INJURIES   OF   REGIONS. 

The  treatment  should  be  directed  towards  the  prevention  of  in- 
flammation of  the  brain,  in  the  way  described  under  fracture  of 
the  vault  (p.  332).  When  the  membrana  tympani  is  ruptured,  an 
attempt  should  be  made  to  prevent  septic  inflammation  by  syring- 
ing out  the  auditory  meatus  with  carbolic  or  corrosive  sublimate 
lotion,  and  applying  an  antiseptic  dressing  over  the  cleansed  ear 
and  shaven  scalp  around.  It  is  true  that  even  when  this  is  done 
a  way  still  remains  open  to  the  tympanum  by  the  Eustachian 
tube  ;  but  it  is  thought  that  the  cilia  prevent  the  access  of  micro- 
organisms by  this  channel.  Should  intra- cranial  inflammation 
supervene,  it  must  be  treated  in  the  way  indicated  under  that 
head  (p.  346). 

Injuries  of  the  Brain  and  its  Me?nbranes. 

Concussion  of  the  brain. — This  term  is  applied  to  a  collection 
of  symptoms  supposed  to  depend  on  a  shaking  or  commotion  of 
the  brain  substance.     It  is  popularly  spoken  of  as  "stunning.'' 

Pathology. — The  exact  condition  of  the  brain  that  gives  rise  to 
the  symptoms  which  go  by  the  name  of  concussion  is  not  known. 
By  some  it  is  believed  that  they  depend  on  the  mere  shock  to  the 
brain — that  there  is  some  vibration  or  molecular  disturbance  of  its 
particles,  or  anaemia  of  its  substance  induced  by  spasm  of  the 
small  arteries,  and  that  the  shock  may  prove  fatal  in  this  way 
without  any  lesion  being  discovered  after  death.  Generally,  how- 
ever, a  slight  contusion  or  laceration  of  the  brain,  or  punctiform 
extravasations  of  blood  in  its  substance  have  been  found,  and  to 
such  some  attribute  the  symptoms  of  concussion.  In  the  few 
cases  that  have  been  immediately  fatal  after  a  blow  on  the  head 
without  any  obvious  lesion  having  been  discovered  in  the  brain, 
the  post-mof-tetn  examination  has  been  unfortunately  incomplete. 
Hence  it  is  maintained  by  those  who  hold  that  there  is  always  an 
obvious  lesion,  that  death  in  these  cases  might  have  resulted  from 
other  mischief,  such  as  fracture  of  the  cervical  spine. 

Symptoms. — Concussion  may  be  divided  into  two  stages  :  i. 
Insensibility;  2.  Reaction,  i.  The  first  stage  corner  on  imme- 
diately on  the  receipt  of  injury;  it  may  be  quite  transitory,  the 
y)atient  merely  losing  consciousness  for  a  few  minutes,  and  then 
recovering  com[)letely  ;  or  it  may  last  for  a  few  hours  or  a  few 
days,  or  even  longer.  The  patient  lies  in  an  unconsious  condi- 
tion, but  can  be  roused  momentarily  on  shaking  him,  or  shouting 
in  his  ear.  There  is  loss  of  all  power  of  motion  ;  the  pulse  is 
feeble,  fluttering,  often  frequent ;  the  respirations  are  shallow,  and 
quiet  or  sighing ;  and  the  syrface  is  cold,  often  clammy,  the  tem- 
perature sometimes  being  as  low  as  97  or  96.     The  pupils  are 


COMPRESSION   OF   THE    BRAIN.  337 

variable,  but  sensitive  to  light.  The  sphincters  are  often  relaxed 
at  the  time  of  injury,  allowing  the  involuntary  passage  of  faeces 
and  urine,  but  are  not  paralyzed.  This  condition,  after  lasting 
for  a  variable  time,  usually  passes  gradually  into  the  second  stage 
— that  of  reaction;  or  symptoms  of  compression  or  of  inflamma- 
tion of  the  brain  may  come  on  without  the  patient  recovering 
consciousness.  2.  The  second  stage,  or  that  of  reaction,  is  marked 
by  a  gradual  return  to  consciousness,  and  is  usually  preceded  by 
vomiting,  which  is  therefore  regarded  as  a  favorable  omen.  The 
skin  becomes  warm,  the  pulse  increased  in  frequency,  and  the 
temperature  slightly  raised.  These  symptoms  commonly  termi- 
nate in  complete  convalescence,  or  they  may  run  into  those  of 
inflammation  of  the  brain.  At  times,  however,  the  patient  may 
relapse  into  a  state  of  unconsciousness  and  die,  or  certain  impair- 
ments of  brain  function  may  remain. 

The  remote  effects  of  concussion  may  be  enumerated  as  head- 
ache, confusion  of  thought,  mental  irritability,  impaired  virility, 
optic  neuritis  and  atrophy,  epilepsy,  or  even  insanity.  These  after- 
effects are  more  likely  to  occur  if  there  is  an  inherited  predispo- 
sition to  nervous  diseases,  and  appear  to  be  brought  on  by  excite- 
ment, abuse  of  stimulants,  or  excesses  in  diet.  In  some  of  these 
cases  the  brain  has  been  examined  after  death,  but  no  organic 
lesion  has  been  found. 

Treatment. — The  chief  indication  is  to  restore  the  cerebral 
functions  by  promoting  the  cerebral  circulation,  taking  care  not 
to  produce  too  violent  a  reaction.  Thus  the  patient  should  be 
placed  at  perfect  rest;  warmth  applied  to  the  surface  by  means 
of  blankets,  hot  bottles,  and,  if  necessary,  by  friction ;  and  small 
quantities  of  diffusible  stimulants,  as  ammonia  or  warm  tea,  ad- 
ministered. Alcohol  should  not  as  a  rule  be  given.  When  reac- 
tion has  come  on,  inflammation  must  be  warded  off  by  gentle 
purgatives,  low  diet,  and  the  avoidance  of  stimulants  and  of  mental 
exertion. 

Compression  of  the  brain  may  be  caused  by:  i.  A  fragment 
of  depressed  bone ;  2.  Extravasated  blood;  3.  Pus,  or  other  in- 
flammatory products  ;  and  4.  A  foreign  body,  such"  as  a  bullet. 

The  signs  of  compression,  i.e.,  of  pressure  on  the  brain,  vary 
according  as  the  compression  is  made  over  a  wide  area  oris  local- 
ized to  a  particular  part.  Thus,  when  the  pressure  is  diffused 
over  a  considerable  portion  of  the  brain,  the  patient  lies  in  a  com- 
pletely unconscious  state,  and  cannot  be  roused  either  by  shouting 
in  his  ear  or  by  shaking  him.  The  extremities  on  one  or  both 
sides  are  paralyzed  ;  the  face  is  livid,  at  times  flushed  ;  the  tem- 
perature is  usually  low,  but  at  times  raised ;  the  pulse  is  full  and 
slow,  often  not  beating  more  than  40  to  the  minute ;  the  respira- 
15 


338  INJURIES   OF   REGIONS. 

tion  is  slow,  labored,  and  stertorous,  /.  e.,  a  peculiar  noise  is  made 
during  expiration  by  the  flapping  of  the  paralyzed  soft  palate  ; 
the  cheeks  and  lips  puff  out  at  each  expiration  in  consequence  of 
paralysis  of  the  buccinator  and  muscles  of  the  lips  ;  the  pupils  are 
fixed  (/.<?.,  the  iris  does  not  respond  to  light),  and  may  be  either 
dilated  or  contracted,  or  one  may  be  dilated  and  the  other  con- 
tracted ;  the  urine  is  at  first  retained  owing  to  the  paralysis  of  the 
muscular  coat  of  the  bladder,  but  afterwards  dribbles  away  as  the 
bladder  becomes  over-distended  and  will  hold  no  more  ;  the 
faeces  pass  involuntarily  in  consequence  of  paralysis  of  the  sphinc- 
ters ;  at  times  there  are  violent  convulsions.  When  on  the  other 
hand  the  pressure  is  localized  the  coma  is  usually  less  profound, 
the  pupil  on  one  side  only  may  be  fixed  and  the  paralysis  maybe 
limited  to  one  side,  possibly  to  an  arm  or  leg,  or  to  one  side  of 
the  face,  or  there  may  be  convulsive  twitching  of  certain  muscles 
or  of  a  limb.  The  compression-symptoms  may  gradually  deepen 
till  the  patient  dies ;  or  he  may  recover  on  the  removal  of  the 
cause,  e.g.,  a  piece  of  bone  or  a  clot  of  blood. 

The  diagnosis  of  the  cause  of  the  compression  will  rest  on  the 
fact  that  when  due  to  bone  or  blood  the  symptoms  come  on  within 
twenty-four  hours  of  the  injury,  generally  directly  if  due  to  bone, 
or  after  a  brief  interval  of  consciousness  if  due  to  blood  ;  but  not 
till  three  or  four  days  after  the  injury  if  due  to  the  pressure  of  in- 
flammatory exudation  or  of  pus,  in  which  case,  moreover,  they 
are  preceded  by  signs  of  inflammation.  Where  the  signs  are  gen- 
eral, as  given  above,  the  injury  usually  depends  upon  the  pressure 
of  extravasated  blood  on  some  of  the  central  portions  of  the  brain 
following  upon  laceration  of  the  brain-substance,  or  upon  general 
inflammation  of  the  brain  or  its  membranes.  But  when  the  signs 
are  those  of  local  pressure  on  the  surface  of  the  brain,  the  lesion 
will  probably  be  due  to  a  depressed  portion  of  bone  or  a  circum- 
scribed extravasation  of  blood  between  the  bone  and  dura  mater, 
or  a  collection  of  pus  either  between  the  bone  and  dura  mater  or 
in  the  cortical  substance  of  the  brain. 

The  treatment  will  necessarily  depend  upon  the  cause  of  the 
compression.  'I'hus  a  depressed  fragment  of  bone  should  be  re- 
moved (see  dep?-essed  f-ac/ure)  ,3.  clot  between  the  bone  and  dura 
mater  let  out  by  the  trephine,  and  a  circumscribed  collection  of 
pus  between  the  bone  and  dura  mater,  or  in  the  membranes  or 
brain,  also  evacuated  by  the  trephine.  But  when  the  compression 
depends  upon  extravasated  blood  in  the  subdural  or  subarachnoid 
space  or  substance  of  the  brain,  or  upon  a  general  inflammation 
of  the  brain  and  its  membranes,  no  surgical  procedui-e  is  of  any 
avail.  In  any  case,  therefore,  the  first  point  to  consider  in  re- 
gard to  treatment  is  whether  the  compression  of  the  brain  is  due 


EXTRAVASATION   OF   BLOOD.  339 

to  a  removable  cause,  or  to  one  that  is  beyond    the  reach  of 
surgery. 

Extravasation  of  blood  in  the  cranium  may  occur — i.  Be- 
tween the  bone  and  dura  mater;  2.  In  the  subdural  space;  3. 
In  the  subarachnoid  space  ;  and  4.  In  the  substance  of  the  brain. 

1.  Blood  between  the  hone  and  dura  mater  {subcranial extra- 
7'asatio?i)  is  generally  due  to  rupture  of  the  middle  meningeal 
artery,  especially  its  anterior  branch,  and  is  commonly  associated 
with  a  fissured  fracture  extending  across  the  line  of  the  arteiy. 
At  times  it  is  due  to  a  wound  of  the  lateral  sinus  or  a  laceration 
of  some  of  the  small  vessels  which  run  from  the  dura  mater  into 
the  bone.  The  blood  is  usually  extravasated  in  large  quantities, 
widely  separating  the  dura  mater  from  the  bone,  and  producing 
severe  compression  of  the  brain.  Should  the  patient  survive,  the 
blood  may  become  organized  or  absorbed. 

2.  Subdural  extravasation  is  due  to  rupture  of  capillary  vessels, 
and  is  very  common  in  severe  head  injuries.  The  blood  usually 
extends  widely  over  the  surface  of  the  arachnoid,  and,  if  the 
patient  survive,  may  become  absorbed  or  organized,  forming  a 
false  membrane,  and  in  some  cases  a  blood-cyst. 

3.  Subarachnoid  extravasation  is  generally  associated  with  con- 
tusion or  laceration  of  the  brain.  The  blood  may  spread  v^idely, 
and  may  become  absorbed,  but  does  not  as  a  rule  become  or- 
ganized. 

4.  Blood  in  the  bi'ain  substance  {intracerebral  extravasation^ 
is  the  result  of  contusion  or  laceration  of  the  brain,  with  rupture 
of  the  small  vessels.  When  the  laceration  is  extensive,  it  is 
usually  fatal;  but  should  the  patient  survive,  the  blood  may 
undergo  changes  similar  to  those  of  an  ordinary  apoplectic  clot, 
or  may  break  down  into  pus  {cerebral abscess). 

The  symptoms  of  intracranial  extravasation  are  those  of  com- 
pression of  the  brain,  but  vary  according  to  the  situation  of  the 
blood  and  the  rapidity  with  which  it  is  extravasated.  The  diag- 
nosis maybe  more  or  less  obscured  by  the  presence  of  concomitant 
injury  to  the  brain,  i.  When  the  blood  is  between  the  bone  and 
dura  mater  the  patient,  to  take  a  typical  case,  is  concussed  at  the 
time  of  the  injury,  recovers  from  the  concussion,  and  is,  perhaps, 
rational ;  then  as  the  action  of  the  heart  becomes  more  forcible 
and  blood  is  poured  out  from  the  wounded  vessel,  he  grows  faint 
and  sinks  into  a  state  of  coma.  The  coma  gradually  deepens, 
and  he  usually  dies  in  from,  a  ^t\\  hours  to  a  few  days  after  the 
injury  with  the  signs  of  profound  compression  of  the  brain.  The 
paralysis  at  first  is  on  the  side  opposite  to  the  injury,  but  may  be- 
come general  as  the  blood  extends  over  the  surface  of  the  brain. 
The  pupil  on  the  side  of  the  injury  may  at  first  react  to  light,  but 


340  INJURIES   OF   REGIONS. 

becomes  dilated  and  fixed  as  the  blood  extends  to  the  base  and 
presses  on  the  third  neive.  At  times  the  eyeball  may  protrude 
owing  to  the  pressure  upon  the  cavernous  sinus.  Very  occasionally 
reflex  convulsions,  also  on  the  side  of  the  injury,  may  be  set  up 
by  irritation  of  the  nerves  of  the  dura  mater.  If  a  fissured  fracture 
is  present,  there  may  be  some  fulness  externally  from  the  escape 
of  blood  through  the  fissure.  2.  When  the  blood  is  in  the  sub- 
dural space,  signs  of  compression  may  be  present ;  but  there  are 
no  special  symptoms  by  which  it  can  be  diagnosed ;  or,  indeed, 
at  times  distinguished  from  blood  between  the  bone  and  dura 
mater.  Irritability  of  temper,  headache,  or  convulsions  coming 
on  some  time  after  the  injury,  are  said,  however,  to  indicate  it. 
3.  When  the  blood  is  beneath  the  arachnoid m  quantities  sufficient 
to  cause  compression,  it  will  probably  be  associated  with  severe 
laceration  of  the  brain,  and  the  patient  will  not,  as  a  rule,  regain 
consciousness.  There  are  no  special  symptoms  by  which  blood 
in  this  situation  can  be  diagnosed  (see  Laceration  of  Brain).  4. 
When  the  blood  is  in  the  brain  substance  it  produces  symptoms 
which  cannot  be  distinguished  from  those  of  apoplexy,  except 
perhaps  by  the  history  of  the  injury,  and  not  always  then,  as  it 
may  be  impossible  to  determine  whether  the  patient  first  fell  and 
thus  injured  his  brain,  causing  effusion  of  blood  into  its  substance, 
or  whether  a  vessel  first  gave  way,  and  the  fall  was  the  conse- 
quence of  the  escape  of  blood  into  the  brain. 

Treat/nent. — When  it  is  clear  that  the  haemorrhage  is  from  the 
middle  meningeal  artery,  and  it  appears  probable  that  no  other 
serious  injury  of  the  brain  has  been  received,  the  trephine  should 
be  applied  for  the  purpose  of  removing  the  clot  and  securing  the 
bleeding  vessel.  The  situation  of  the  artery  is  about  an  inch  and  a 
half  behind  the  external  angular  process  of  the  orbit,  and  over  this 
spot  a  crown  of  bone  should  be  removed.  The  dark  clot  which 
now  protrudes  at  the  opening  should  be  turned  out  by  some  form 
of  scoop,  and  if  the  bleeding  artery  is  then  seen,  an  attempt  should 
be  made  to  tie  or  twist  it,  or  to  compress  it  by  plugging  the  groove 
in  the  bone  in  which  it  lies  with  a  piece  of  aseptic  wax  or  wood. 
If  the  bleeding  point  cannot  be  reached,  more  bone  may  be  cut 
away.  If,  however,  on  the  removal  of  the  clot,  the  brain  does  not 
expand,  and  the  haemorrhage  is  so  profuse  that  the  wounded 
artciy  cannot  be  seen,  the  external  or  common  carotid  artery  may 
be  compressed  or  tied,  and  ice  apijlied  to  the  side  of  the  head. 
When  no  blood  is  found  between  the  bone  and  dura  mater,  but 
the  dura  mater  itself  is  bluish  in  color,  does  not  pulsate  with  the 
brain,  and  bulges  into  the  trephine  hole,  indicating  the  presence 
of  blood  beneath  it,  an  incision  should  be  made  through  it  and  the 
blood  let  out.     Great  care  must  subsequently  be  taken  to  keep 


LACERATION   OF   THE   BRAIN.  34 1 

the  wound  aseptic.  For  hccmorrhage  on  the  surface  or  in  the 
substance  of  the  brain  surgical  interference  is  not  permissible  ;  all 
that  can  be  done  is  to  treat  the  case  as  one  of  ordinary  apoplexy 
from  cerebral  haemorrhage,  /.  e.,  by  free  purging,  cold  to  the 
head,  hot  bottles  to  the  feet,  etc. 

Contusion  or  bruising  of  the  brain  may  be  due  to  any 
severe  violence,  and  may  occur  with  or  without  injury  of  the  scalp 
or  cranial  bones.  It  is  often  accompanied  by  laceration  of  the 
brain  substance  and  of  the  pia  mater  and  arachnoid.  The  bruis- 
ing may  be  general  or  circumscribed.  In  the  latter  case  it  may 
occur  immediately  beneath  that  part  of  the  cranium  to  which  the 
violence  was  applied,  or  on  the  opposite  part  of  the  brain,  the 
brain  being  as  it  were  dashed  by  the  violence  of  the  blow  against 
the  cranial  wall  furthest  from  the  part  of  the  skull  to  which  the 
force  was  applied.  Like  bruises  of  other  soft  tissues  it  is  attended 
by  extravasation  of  blood  from  rupture  of  the  smaller  vessels.  It 
may  terminate  in  absorption  of  the  blood  and  healing  of  the 
bruised  parts,  or  in  general  inflammation  of  the  brain  and  its 
membranes,  or  in  local  inflammation  and  cerebral  abscess.  The 
sympto77is  are  generally  obscured  by  those  of  concussion  or  com- 
pression, and  it  is  seldom  that  an  accurate  diagnosis  can  be  made. 
Irritability,  restlessness  and  spasms  of  certain  muscles,  when  a 
motor  centre  is  injured,  are  said,  however,  to  point  to  contusion. 
The  chief  indication  for  treatment  is  to  prevent  the  occurrence 
of  inflammation  of  the  brain  (see  p.  346). 

Lacfration  of  the  brain  may  occur  with  or  without  fracture 
or  other  injury  of  the  skull.  The  laceration  is  most  common  in 
the  anterior  part  of  the  frontal  and  in  the  temporo-sphenoidal 
lobe,  owing  in  part  to  the  unevenness  of  the  base  of  the  skull  on 
which  these  lobes  rest,  and  in  part  to  the  fact  that  the  back  and 
the  top  of  the  head  are  most  exposed  to  injury,  the  brain,  as  in 
contusion,  being  generally  lacerated  on  the  side  of  the  head  di- 
rectly opposite  to  that  on  which  the  force  is  received.  At  times, 
however,  the  brain  is  lacerated  directly  beneath  that  part  of  the 
skull  to  which  the  force  is  applied.  Laceration  may  also  be 
caused  by  a  fragment  of  bone,  as  in  depressed  or  punctured  frac- 
ture, or  by  the  passage  of  a  bullet  or  the  thrust  of  a  sword  through 
the  orbit  or  nose. 

Fathoh^y. — The  laceration  may  be  slight  or  very  extensive,  and 
is  generally  accompanied  by  more  or  less  bniising  of  the  surround- 
ing brain-tissue  and  extravasation  of  blood  over  its  surface.  The 
pia  mater  is  also  lacerated,  and  where  the  injury  is  produced  by 
a  fragment  of  bone  the  dura  mater  is  likewise  torn,  and  in  some 
cases  large  portions  of  the  lacerated  brain  may  protrude  through 
the  skull,     Inflammation  of  the  brain  and  its  membranes  is  liable 


342 


IN'JURIES   OF   REGIONS. 


Fig. 


to  follow,  and  to  assume  a  septic  character,  and  spread  widely  if 
there  is  an  external  wound  which  has  not  been  kept  aseptic. 
Should  the  patient  recover,  cicatrization,  with  adhesion  of  the 
membranes,  occurs,  the  extravasated  blood  in  the  meantime 
undergoing  the  changes  already  described. 

The  syinpto)ns  vary.  At  times  there  may  be  none,  although  a 
considerable  mass  of  brain  tissue  is  protruding  through  a  fracture 
in  the  skull.  Or  they  may  be  obscured  by  signs  of  concussion, 
or  if  much  blood  has  been  extravasated,  by  those  of  compression. 
There  are  no  signs  pathognomonic  of  laceration  of  the  brain,  but 

convulsions,  localized  spasms 
or  paralysis,  long- continued 
insensibility  without  coma, 
and  the  collection  of  symp- 
toms known  as  cerebral  irri- 
tation, point  to  such  an 
injury.  .  The  symptoms  of 
cerebral  irritation  may  be 
described  as  follows :  The 
patient  lies  in  a  torpid  or 
semi-conscious  condition, 
coiled  up  on  one  side,  with 
his  limbs  in  a  general  state 
of  flexion.  If  spoken  to  he 
evinces  great  irritability  of 
temper,  answering  moment- 
arily and  sharply,  perhaps 
shaking  himself,  and  then 
relapses  into  his  torpid  state. 
His  pupils  are  contracted, 
his  eyes  closed,  but  his 
pulse,  tem])erature,  and  re- 
spirations are  normal.  Is 
there  any  way  of  localizing 
the  seat  of  the  hiceration 
where  no  external  injury  ex- 
ists? "  If  a  patient  receive  a  blow  upon  the  head,  and  it  is  found 
that  localized  paralysis  is  present,  we  conclude  that  there  exists 
a  laceration  of  some  severity  in  the  cortical  centre  corresponding 
to  the  muscles  imj)licated.  If  almost  immediately  after  the  in- 
jury there  is  a  distinct  spasm  affecting  a  localized  group  of  mus- 
cles— a  monospasm — we  conclude  that  heemorrhage  is  going  on 
from  the  lacerated  brain  substance,  or  breaking  down  the  tissue 
of  the  centre  corresjjonfling  to  the  affected  muscles.  If  the 
monospasm   extends,   first  affecting  one  side  of  the  body,  and 


The  cerebral  convolutions:  R,  fissure  of  Rolanuo; 
F',  ascending  frontal  convolution;  P',  ascend- 
ing parietnl  convolution;  F',  F-,  F^,  superior, 
middle,  and  inferior  frontal  convolutions;  S  F, 
superior  frontal  sulcus;  I  F,  inferior  frontal 
sulcus;  S,  fissure  of  Sylvius;  S",  anterior  limb 
of  fissure  of  Sylvius;  Si',  posterior  limb  of  fissure 
of  Sylvius;  P-,  superior  parietal  convolution; 
P',  supra-marginal  convolution;  P',  angular 
convolution;  I  P,  intcr-parielal  fissure;  1'  S', 
T  S",  T  S ',  superior,  middle,  and  inferior  tem- 
poro-sphenoidal  convolutions;  B,  Proca's  con- 
volution; P",  parieto-occipital  fissure;  ()',0-, 
O'',  superior,  middle,  and  inferior  occipital  con- 
volutions. (After  Lucas-Championniere  and 
Erichsen.) 


LACERATION    OF   THE    BRAIN. 


343 


Fig.  114. 


finally  both  sides,  so  that  the  attacks  assume  the  form  of  true  epi- 
leptic fits,  it  is  probable  the  extravasated  blood  is  extending  over 
the  surface  of  the  brain  and  irritating  more  or  less  widely  the 
whole  motor  area"  {Erichsen).  Should  there  be  motor  aphasia, 
a  lesion  of  the  posterior  extremity  of  the  third  left  frontal  convo- 
lution {Bi-oca's  convolution)  is  indicated  (Fig.  113,  b).  Should 
there  be  facial  spasm  or  paralysis,  a  lesion  of  the  lower  third  of 
the  ascending  frontal  and  the  contiguous  part  of  the  posterior 
end  of  the  second  frontal  convolution  is  probably  present  (Fig. 
113,  F*,  f').  Should  there  be  paralysis  of  the  arm — a  brachial 
monoplegia — the  middle  portion  of  the  ascending  frontal  and 
the  contiguous  part  of  the  ascending  parietal  on  the  other  side  of 
the  fissure  of  Rolando  are  probably  affected  (Fig.  113,  r'  and  p'). 
Should  there  be  paralysis  of  the  lower  limb,  the  lesion  probably 
involves  the  upper  end  of  the  ascending  parietal  and  the  superior 
parietal  lobule  lying  behind  it,  as  far  as  the  margin  of  thelongi- 
tudinal  fissure  (Fig.  113,  p^  and  p'). 

Briefly,  therefore,  a  cortical  lesion  may  be  distinguished  from 
a  central,  as  follows  :  In  the 
cortical  lesion  the  paralysis, 
although  it  may  occur  im- 
mediately after  the  accident, 
often  does  not  appear  for 
some  time.  It  is  incom- 
plete and  locaUzed,  and  pro- 
bably affects  only  one  hmb 
or  a  single  group  of  muscles. 
In  the  central  lesion,  on  the 
other  hand,  the  paralysis  oc- 
curs immediately  after  the 
injury;  it  is  more  complete 
and  extensive,  and  the 
whole  of  one  side,  at  least, 
will    probably  be  paralyzed. 

The  treatment  should  be  directed  to  the  prevention  of  inflam- 
mation in  the  way  already  described.  If  there  is  a  wound,  with 
protrusion  of  the  brain,  the  contused  and  protruded  portions  and 
any  fragments  pressing  upon  or  penetrating  the  brain  substance 
should  be  removed,  the  wound  cleansed  with  antiseptics,  the 
scalp  replaced,  and  its  union  by  the  first  intention  sought.  In 
the  case  of  a  gunshot  wound  the  bullet  should  be  removed  if  it 
can  easily  be  got  at,  otherwise  it  should  be  left  in  situ.  Where 
there  is  no  wound,  but  signs  of  local  irritation  or  of  compression 
of  the  cortical  motor  area  from  blood-extravasation,  the  indica- 
tions are  to  trephine.     The  guide  to  the  spot   for  perforation  ^is 


The  situation  of  the  line  of  Rolando. 


344  INJURIES   OF   REGIONS. 

the  line  of  the  fissure  of  Rolando  on  the  side  opposite  to  that  of 
the  localized  spasm  or  paralysis.  This  line  may  be  found  in  var- 
ious ways.  M.  Lucas-Championniere  employs  the  following 
method  (see  Fig.  114)  :  He  first  finds  the  bregma,  /.  e.,  the  spot 
where  the  coronal  joins  the  sagittal  suture,  by  carrying  a  line  di- 
rectly over  the  vortex  from  one  external  auditory  meatus  to  the 
other.  The  upper  end  of  the  Rolandic  fissure  is  situated  about 
2  inches  behind  the  bregma.  The  lower  end  of  the  fissure  cor- 
responds to  a  spot  2  3/_^  inches  behind  the  external  angular  process 
and  about  i  inch  above  it.  We  have  already  seen  that  the  corti- 
cal motor  centres  are  grouped  around  the  Rolandic  fissure.  If 
therefore  there  is  general  hemiplegia,  the  perforation  should  be 
made  over  the  middle  of  the  line  ;  if  paralysis  of  the  arm  and  leg, 
over  the  upper  part  of  the  line  ;  if  paralysis  of  the  arm  only,  in 
front  of  the  middle  third  of  the  line  ;  if  aphasia,  below  and  a  little 
in  front  of  the  line  on  the  left  side  of  the  head  ;  if  there  is  paraly- 
sis of  the  leg  alone,  behind  the  upper  third  of  the  line  ;  if  paraly- 
sis of  the  arm  and  face,  in  front  of  the  lower  third  of  the  line  ;  if 
paralysis  of  the  arm  and  aphasia,  or  paralysis  of  the  face  and 
aphasia,  below  and  in  front  of  the  line. 

Intracranial  inflammation,  though  at  times  it  may  remain 
localized  either  to  the  membranes  {meningitis^  or  to  the  brain 
{encephalitis^,  more  often,  in  whatever  way  it  begins,  spreads 
from  the  one  to  the  other  {nieningo-encephnlitis) . 

Cause. — Wounds  of  the  scalp  ;  contusions  or  fractures  of  the 
bone ;  concussion,  contusions,  lacerations,  and  penetrating 
wounds  of  the  brain. 

Pathology. — It  may  be  acute  or  chronic  :  septic  or  diffuse,  or 
simple  and  circumscribed.  Acute  inflammation  may  begin  in  the 
dura  mater, and  remain  confined  to  that  membrane  {pachymenin- 
gitis) or  spread  inwards  to  the  other  membranes  and  the  brain; 
or  it  may  begin  in  the  brain,  but  then  seldom  spreads  further  out- 
wards than  the  pia  mater  {leptomeningitis).  When  it  begins  in 
the  bone  or  in  the  dura  mater,  it  is  at  first  circumscribed,  the  in- 
flammatory products,  and,  should  suppuration  occur,  the  pus  be- 
ing confined  between  the  bone  and  dura  mater.  Later,  the  in- 
flammation may  spread  to  the  arachnoid,  and  thence  to  the  pia 
mater  and  surface  of  the  brain,  diffusing  itself  widely  through  the 
subdural  space  and  over  the  cerebral  cortex.  When  it  begins  in 
the  brain,  it  is  generally  the  result  of  a  contusion  or  laceration  of 
the  cerebral  substance,  and  may  remain  circumscribed,  and 
eventually  end  in  a  cerebral  abscess,  or  spread  to  the  pia  mater 
and  then  become  diffuse.  It  seldom,  however,  involves  the  free 
surface  of  the  arachnoid.  The  post-)norte?n  appearances  com- 
monly observed  are   increased  vascularity  of  the  brain  and  its 


INTRACRANIAL    INFLAMMATION.  345 

membranes,  an  exudation  of  greenish-yellow  lymph,  and  disten- 
sion of  the  ventricles  with  a  serous  blood-stained  fluid  ;  whilst 
the  grey-matter  is  of  a  reddish  hue,  soft  and  diffluent,  and  the 
white  more  abundantly  dotted  over  with  "  puncta  vasculosa " 
than  natural.  In  the  chronic  form,  which  is  generally  due  to 
inflammation,  caries  or  necrosis  of  the  bone,  or  more  rarely  to 
a  brain-injury,  the  dura  mater  becomes  thickened  and  adher- 
ent to  the  bone,  the  arachnoid  thickened,  and  the  pia  mater 
opaque  and  indurated,  so  that  when  removed  its  prolongations, 
which  dip  between  the  convolutions,  can  be  pulled  out  without 
tearing. 

The  symptoms  vary  according  as  the  inflammation  is  acute  or 
chronic,  diffuse  or  circumscribed  ;  according  as  it  begins  in  the 
dura  mater  or  in  the  brain  and  pia  mater ;  and  accordmg  as  it 
involves  the  vertex  or  base  of  the  brain.  The  general  symptoms 
in  acute  cases  are  in  the  early  stages,  fever,  pain  in  the  head, 
generally  on  the  same  side  as  the  wound,  if  one  is  present,  intol- 
erance of  light  and  sound,  retching  with  probably  a  clean  tongue, 
a  quick,  full  pulse,  flushed  face,  contracted  pupils,  violent  beating 
of  the  carotids,  restlessness,  sleeplessness,  and  at  times  violent 
delirium.  Later  the  symptoms  pass  into  those  of  compression, 
the  pupils  becoming  dilated  and  fixed,  the  pulse  slow,  and  the 
breathing  stertorous.  Then  follow  paralysis,  stupor,  coma  and 
death.  Rigors  will  probably  occur  should  pus  form.  In  the 
chronic  form  of  inflammation  the  symptoms  are  similar  to  those 
of  the  acute,  but  of  less  severity,  and  are  later,  as  a  rule,  in  mak- 
ing their  appearance.  Complete  recovery  may  have  apparently 
taken  place,  or  there  may  have  been  headache  or  irritability  of 
temper  previous  to  the  symptoms  setting  in.  Is  there  any  way 
of  loca/izing  the  inflammation?  i.  If  ten  to  twenty  days  have 
elapsed  since  the  injury ;  if  the  onset  of  the  symptoms  is  sudden, 
though  preceded  perhaps  by  some  headache;  if  there  is  a  puify 
swelling  over  the  seat  of  injury,  due  to  the  separation  of  the  peri- 
cranium from  the  bone  by  serous  effusion  ;  if  the  bone,  should  it 
be  exposed,  looks  dry,  white,  and  discolored,  or  the  wound  un- 
healthy ;  and  if  the  paralysis  is  localized — the  inflammation  is 
probably  between  the  bone  and  dura  mater,  and  if  a  rigor  has 
occurred,  pus  has  probably  formed.  2.  If,  on  the  other  hand, 
there  is  no  apparent  mjury  of  the  scalp  or  bone ;  if  the  patient 
has  had  concussion  ;  and  if  the  symptoms  set  in  a  few  hours  after 
the  injury — the  inflammation  is  probably  in  the  brain  or  pia  mater, 
where  it  has  arisen  in  consequence  of  increased  vascularity  follow- 
ing the  concussion.  Or  if  the  symptoms  come  on  about  the  fourth 
or  fifth  day  after  the  injury,  when  it  had  apparently  been  recov- 
ered from,  the  inflammation  will  probably  be  also  in  the  brain  or 


346  INJURIES    OF    REGIONS. 

pia  mater,  but  in  this  case  due  to  contusion  or  laceration  of  the 
brain.  3.  If,  again,  the  symptoms  are  delayed  some  weeks,  if 
there  is  optic  neuritis  or  symptoms  of  disturbance  of  one  or  more 
of  the  motor  areas,  the  inflammation  is  probably  localized  to  some 
portion  of  the  brain,  and  if  a  rigor  has  occurred,  a  cerebral  ab- 
scess has  probably  formed. 

The  treatment  may  be  divided  into  the  preventive  and  the  cura- 
tive. The  former  consists  briefly  in  guarding  against  the  occur- 
rence of  septic  changes  in  the  wound,  if  one  is  present,  and  in 
preventing  congestion  of  the  brain  and  its  membranes  by  the 
means  already  indicated  (see  p.  332).  The  first  signs  of  inflam- 
mation should  be  actively  combated  by  a  calomel  purge,  leeches 
to  the  temples  and  an  ice-bag  to  the  head  ;  whilst  pain  should  be 
subdued  and  sleep  promoted  by  the  cautious  use  of  opium.  The 
curative  treatment  consists  in  evacuating  the  products  of  the  in- 
flammation, should  such,  in  spite  of  the  preventive  treatment, 
ensue.  Thus,  if  there  are  signs  of  local  suppuration  between  the 
bone  and  dura  mater,  the  trephine  should  be  applied  over  the 
seat  of  injury,  or  if  one  is  not  apparent,  over  the  motor  area  at  the 
spot  indicated  by  localized  paralysis  or  spasm.  If,  on  removing 
the  bone,  the  dura  mater  is  seen  to  bulge,  and  the  pulsations  of 
the  brain  cannot  be  felt,  the  dura  mater  should  be  perforated, 
and  if  pus  is  still  undiscovered,  but  the  signs  of  suppuration  are 
well  marked,  an  exploring  needle  should  be  cautiously  passed  into 
the  brain-substance.  If  there  are  signs  of  cerebral  abscess,  a  tre- 
phine should  be  applied  over  the  suspected  spot,  the  dura  mater 
incised,  the  brain  carefully  punctured,  and  if  pus  is  discovered,  a 
free  incision  made  to  let  it  out.  If  the  suppuration  appears  to 
be  general  rather  than  local,  no  operative  treatment  should  be 
undertaken. 

Hernia  cerebri  is  a  protrusion  of  brain-substance  through  a 
hole  in  the  cranium  and  dura  mater.  Cause. — It  appears  to  be 
due  to  a  localized  swelling  of  the  brain,  conseqiient  upon  inflam- 
mation, and  may  occur  after  any  injury  of  the  cranium  where  there 
is  loss  of  bone  and  a  wound  or  sloughing  of  the  dura  mater,  with 
bruising  or  laceration  of  the  brain.  Patho/oQ'. — The  protrusion 
consists  of  brain-substance  infiltrated  with  inflammatory  products 
and  blood,  and  is  the  result  of  the  inflammatory  swelling  finding 
a  vent  in  the  only  possible  way  in  which  it  can  escape,  viz., 
through  the  hole  in  the  cranium.  The  effused  blood  is  due  to 
the  rupture  of  the  obstructed  capillaries,  consequent  upon  the 
protruding  mass  becoming  constricted  by  the  margins  of  the 
aperture  through  which  it  is  protruding.  At  times,  when  the  rup- 
ture of  the  capillaries  is  extensive,  the  tumor  consists  almost  en- 
tirely of  clotted  blood.     Signs. — The  hernia  appears  a^s  a  reddish- 


TREPHINING   THE   SKULL.  347 

brown,  blood-stained,  fungus-looking  mass,  overhanging  the  hole 
in  the  cranium,  through  which  it  has  protruded,  and  often  pulsa- 
ting synchronously  with  the  brain.  Should  the  inflammation  sub- 
side, the  protrusion  will  gradually  recede  and  the  patient  recover  ; 
but  should  it  continue,  the  hernia  will  increase  in  size,  and  as 
more  and  more  of  the  brain  is  involved,  the  patient  sinks  into  a 
comatose  state  and  dies.  At  times  the  protrusion  may  become 
constricted  at  its  base,  and  slough  away  and  the  parts  cicatrize  ; 
or  an  abscess  may  form  in  its  interior  and  in  the  contiguous  part 
of  the  brain,  and  death  result  from  cerebral  compression.  The 
treatment  consists  in  attempting  to  allay  the  inflammation  of  the 
brain,  which  is  the  cause  of  the  hernia,  by  the  means  already  de- 
scribed in  Intracranial  Inflammation.  Formerly,  pressure  on  the 
protrusion,  shaving  it  off,  and  applying  caustics,  were  the  means 
employed,  but  they  were  not  attended  with  success,  and  are  now 
discarded. as  unscientific.  Pressure  would  rather  tend  to  cause 
an  abscess  or  promote  inflammation  by  keeping  up  tension.  The 
hernia  itself  should  be  left  alone,  except  when  the  inflammation 
has  become  chronic,  when  well-regulated  pressure  may  possibly 
promote  the  absorption  of  inflammatory  products  and  the  shrink- 
ing and  recession  of  the  mass. 

Trephining  the  skull  is  indicated  : — i.  In  all  cases  of  punc- 
tured fracture.  2.  In  depressed  fracture  with  symptoms  of  com- 
pression, whether  simple  or  compound.  3.  In  localized  extrava- 
sations of  blood  between  the  bone  and  dura  mater.  4.  In  intra- 
cranial suppuration  when  the  pus  is  circumscribed  and  situated 
between  the  bone  and  dura  mater,  in  the  subdural  or  subarach- 
noid space,  or  in  the  substance  of  the  brain.  5.  For  the  removal 
of  a  bullet  lodged  in  an  accessible  situation  in  the  brain.  6.  In 
fracture  of  the  inner  table.  7.  In  epilepsy,  mania,  and  continued 
headache  following  on  head-injury.  8.  For  the  removal  of  a 
cerebral  tumor.  9.  In  microcephaly  with  idiocy.  10.  In  com- 
pound depressed  fracture  without  symptoms,  in  which  the  frag- 
ments cannot  be  raised  by  the  elevator,  opinions  differ  as  to  the 
propriety  of  trephining.  If  the  depression  is  considerable,  I 
think  it  ought  to  be  done,  as  should  the  patient  escape  the  imme- 
diate danger  of  intracranial  inflammation,  he  is  liable  to  certain 
remote  effects  from  the  irritation  of  the  depressed  fragments,  such 
as  headache,  epilepsy,  mania,  etc.  {^see  Depressed  Fracture^  p. 
332).  The  operation.— \i  a  wound  of  the  scalp  exists,  it  should 
be  enlarged,  otherwise  a  large  semi-circular  flap  of  the  scalp 
should  be  turned  down,  so  that  when  it  is  replaced  after  the  ope- 
ration the  trephine-hole  is  completely  covered.  The  pericranium 
having  been  turned  back  from  the  bone,  the  trephine,  with  the 
pin  protruded  one-tenth  of  an  inch,  should   be   apphed,   and 


34? 


INJURIES   OF   REGIONS. 


Fig.  lis. 


Steadily  worked,  clearing  the  teeth  from  time  to  time  with  an 
aseptic  sponge  or  the  brush  provided  for  the  purpose  in  the 
trephine-case.  A  good  groove  having  been  formed  in  the  bone, 
the  pin  should  be  withdrawn.  When  the  diploe  is  reached, 
which  may  be  known  by  the  bone-dust  being  soft  and  red,  greater 
caution  must  be  used,  and  a  quill  or  probe  introduced  into  the 
groove  at  intervals  to  ascertain  whether  perforation  has  taken 
place  at  any  situation.  When  the  crown  of  bone  is  loose  it  should 
be  removed  with  the  sequestrum  forceps,  and  if  it  is  intended  to 
replace  it,  it  should  be  kept  warm  in  some  weak  antiseptic  solu- 
tion, and  at  the  end  of  the  operation,  cut  into  small  pieces  and 
placed  in  the  hole,  and  the  flap  laid  down  over  it.  If  more  room 
is  necessary,  the  trephine  hole  may  be  enlarged  by  a  Hey's  saw, 
Hoffman's  or  Keen's  forceps,  or  by  the  surgical  engine.  It  need 
hardly  be  said  that  the  strictest  antiseptic  precautions  should  be 
used  throughout.  Thus,  the  whole  scalp  should  be  shaved,  and 
washed  with  soap  and  hot  water,  then  with 
ether,  turpentine,  or  ammonia,  to  remove  all 
grease,  and  afterwards  with  perchloride  of 
mercury  or  other  antiseptic.  Healing  by  the 
first  intention  should  be  obtained  if  possible 
by  accurately  uniting  the  wound,  except  per- 
haps at  its  lowest  part,  which  may  be  left 
open  for  drainage,  and  by  applying  a  dry 
antiseptic  dressing,  and  over  it  an  ice-bag  to 
prevent  inflammation.  The  trephine  should 
not  be  applied,  as  a  rule,  over  a  suture,  an 
air  or  venous  sinus,  or  over  the  middle 
meningeal  artery,  unless  the  operation  is 
undertaken  with  a  view  to  secure  that  vessel. 
The  conical  trephine,  shown  in  Fig.  115,  will 
be  found  a  safer  instrument  than  that  in 
ordinary  use,  as  with  it  the  dura  mater  is  less 
likely  to  be  injured,  and  the  handle  also  is 
more  comfortable  to  work  with.  It  can  now 
be  had  with  a  metal  handle  and  the  im])roved  button  pin.  Before 
trephining  for  the  removal  of  a  cerebral  tumor,  morphia  should 
be  given,  as  it  causes  contraction  of  the  small  blood-vessels,  and 
so  has  a  tendency  to  lessen  the  hajmorrhage.  The  anaesthetic, 
however,  especially  if  chloroform  is  chosen,  should  be  given  in 
much  smaller  quantities  when  the  ])atient  is  under  the  influence 
of  morphia. 

INJURIES  OF  THE  FACE. 

Contusions  of  the  face  are  very  common.     Amongst  them  may 


Conical  trephine,  with 
the  author's  improved 
handle. 


FOREIGN   BODIES   IN  THE   NOSE. 


349 


Fig.  ii6. 


•)/ 


I 


be  mentioned  "  black-eye,"  which  is  attended  with  extravasation 
of  blood  in  the  loose  cellular  tissue  of  the  eye- 
lids. The  swelling  is  often  very  great,  the  eye 
being  completely  closed,  but  it  usually  subsides 
in  a  few  days.  Suppuration  occasionally  oc- 
curs, a  small  incision  then  becoming  necessary. 

Wounds  of  the  face,  owing  to  the  great 
vascularity  of  the  parts,  readily  and  rapidly 
heal.  The  edges  of  the  wound  should  be  ap- 
proximated as  accurately  as  possible,  espec- 
ially when  near  the  eyelids,  where  there  is 
danger  of  contraction,  and  united  with  horse- 
hair sutures.  If  quite  superficial,  the  wound 
may  then  be  sealed  with  collodion,  but  if  deep 
the  surfaces  should  be  supported  by  hare-lip 
pins  or  wire  sutures,  which,  however,  to  pre- 
vent scarring,  should  be  removed  at  the  end  of 
thirty-six  hours.  Wounds  attended  by  loss  of 
substance  may  subsequently  require  a  plastic 
operation. 

Foreign  bodies  in  the  nose. — Peas,  beads, 
pebbles  and  the  like  are  sometimes  pushed  up 
the  nose  by  children,  where    they   sooner  or 
later  give  rise  to  irritation  and  a  muco-purulent 
and  foetid  discharge.     Indeed,  the  presence  of 
such  a  discharge  from   one  nostril  in  a  child 
should  always  lead  the  surgeon  to  make  a  care- 
ful search,  if  necessary  under  an  anaesthetic,  for 
a  foreign  body.     The  collar-stud  and  portion 
of  lace  trimming  shown  in  Fig.  ii6  I  removed 
from  the  nose  of  a  boy  aged  eight  years.     He 
had  introduced  them  five  years  previously,  and 
they  had  remained  undetected  till  I  saw  him, 
the    discharge    having   been   looked   upon   as 
catarrhal.     If  allowed  to  remain,  for- 
eign bodies  may  cause  ulceration,  or 
even  bone-disease.  They  can  generally 
be  removed   by  forceps,  curettes,  or 
the  nasal  douche,  but  before  these  are 
used  the  patient  should  close  the  op- 
posite   nostril    and    forcibly    expire, 
since  the  body  may  often  be  expelled 
in   this  simple  way.     At  times  they 
have   to    be    pushed    back    into    the 
pharynx.     Milder  means  faihng,  Rouge's  operation  (see  Diseases 


'% 


IT' 


ft 


Collar  stud  and  lace  trimming  (ex- 
act size)  removed  from  the  nose. 
(St.  Bartholomew's  Hospital 
Museum.) 


350  INJURIES   OF   REGIONS. 

of  Nose)  may  become  necessary.  It  should  not  be  forgotten  that 
ioreign  bodies  occasionally  enter  the  nose  from  behind  during 
vomiting. 

Foreign  bodies  in  the  ear  should  be  removed  by  syringing 
with  tepid  water,  and  no  attempt  made  to  extract  them  with  in- 
struments unless  their  nature  is  such  that  the  warmth  and  moisture 
of  the  part  may  cause  them  to  swell,  as  is  the  case  with  peas. 
Under  these  circumstances,  some  of  the  various  aural  curettes, 
snares,  etc.,  devised  for  the  purpose  may  be  used,  but  with  great 
gentleness  and  aided  by  artificial  light,  the  child,  if  unruly,  being 
placed  under  an  anaesthetic.  If  a  rounded  body,  as  a  bead,  which 
is  incapable  of  swelling,  does  not  come  away  on  syringing,  it 
should  be  left  alone  for  the  time,  as  it  will  subsequently,  by  setting 
up  slight  suppuration,  become  loosened,  and  can  then  be  removed 
by  again  using  the  syringe.  The  incautious  use  of  instruments 
has  been  attended  by  perforation  of  the  membrana  tympani,  and 
even  followed  by  fatal  intracranial  inflammation.  As  a  caution  it 
may  be  mentioned  that  the  handle  of  the  malleus  has  ere  now 
been  mistaken  for  a  foreign  body  and  roughly  torn  out. 

Salivary  fistula  occasionally  results  from  a  wound  of  Stenson's 
duct.  It  is  known  by  a  small  fistulous  opening  on  the  cheek  from 
which  saliva  dribbles,  especially  when  food  is  being  taken.  Treat- 
ment.— Numerous  operations  have  been  proposed  and  practiced 
for  this  somewhat  troublesome  condition.  The  principle  under- 
lying them  all  is  first  to  establish  a  free  opening  of  the  duct  into 
the  mouth,  and  then,  if  the  external  opening  does  not  heal,  to 
close  it  by  a  plastic  operation. 

Fracture  of  the  nasal  bones  is  always  the  result  of  severe 
direct  violence.  The  fracture  is  commonly  transverse  in  direc- 
tion, and  is  often  comminuted  and  accom])anied  by  much  dis- 
placement and  at  times  by  emphysema.  Occasionally  the  frac- 
ture extends  through  the  perpendicular  plate  of  the  ethmoid  and 
thence  to  the  cribriform  plate.  Hence  it  may  be  complicated  by 
subsequent  inflammation  of  the  brain  and  its  membranes.  Treat- 
ment.— 'l"he  bones  should  be  manii)ulated  into  i)osition  by  the 
fingers  externally  and  by  a  director  passed  up  the  nostril,  or  by 
the  dressing  forceps  with  one  blade  within  and  one  blade  out- 
side the  nose.  The  fragments  should  then  be  retained  in  posi- 
tion, which  is  often  difficult,  by  pads  of  lint  and  strapping,  or  if 
such  are  insufficient,  by  some  form  of  nose  truss,  such  as  the  au- 
thor's. (See  Diseases  of  Nose.)  They  unite  very  quickly  by 
bony  callus.  The  septum,  where  this  has  been  deflected,  should 
be  straightened,  so  as  to  support  the  depressed  bones,  and  kept 
in  place  by  ivory  plugs  passed  up  the  nostrils,  or  by  other  suitable 
retentive  apparatus.     Where  the  fracture  has  not  been  properly 


FRACTURE   OF   THE  JAWS.  35 1 

reduced  rauch  deformity  may  remain,  and  if  the  septum  has  also 
been  deflected,  considerable  inconvenience  may  be  felt  in  conse- 
quence of  obstruction  to  respiration  through  one  or  other  nostril. 
In  such  cases,  though  a  considerable  period  may  have  elapsed 
from  the  time  of  the  accident,  much  may  be  done  by  forcible 
straightening  to  remedy  the  deformity  (see  Diseases  of  the  Nose). 
The  lateral  cartilages,  if  separated  from  the  nasal  bones,  should 
be  carefully  replaced,  as  if  this  precaution  is  neglected  httle  can 
subsequently  be  done.  Where,  however,  they  are  merely  laterally 
deflected,  the  resulting  deformity  may  be  corrected  by  the  use  of 
a  retentive  apparatus. 

Fractures  of  the  upper  jaw,  or  of  the  malar  bone  with  de- 
pression of  the  zygomatic  arch,  are  occasionally  met  with  in  severe 
smashes  of  the  face.  They  are  often  impossible  to  rectify,  and 
considerable  deformity  frequently  remains.  Although  much  com- 
minution may  occur,  necrosis,  in  consequence  of  the  great  vascu- 
larity of  these  parts,  rarely  results. 

Fracture  of  the  lower  jaw  is  nearly  always  due  to  severe  and 
direct  violence.  The  fracture  may  extend  through  any  portion 
of  the  bone,  but  commonly  occurs  a  Httle  to  one  or  other  side  of 
the  symphysis,  the  hne  of  fracture  being  then  usually  vertical.  In 
this  situation,  and  indeed  whenever  the  fracture  involves  the  alve- 
olar border,  the  mucous  membrane  of  the  gums  is  torn,  rendering 
the  fracture  compound.  It  unites,  however,  nearly  always  like  a 
simple  fracture.  There  is  not  as  a  rule  much  displacement ;  but 
when,  as  occasionally  happens,  there  is  a  fracture  on  both  sides  of 
the  symphysis,  the  central  portion  is  considerably  depressed  by 
the  action  of  the  genio-hyoid  and  digastric  muscles.  When  the 
line  of  fracture  extends  through  the  angle  or  ascending  ramus, 
the  fragments  are  held  in  apposition  by  the  masseter  on  the  outer, 
and  the  internal  pterygoid  on  the  inner  side.  The  fracture  may 
occasionally  occur  through  the  coronoid  process  or  the  neck  of 
the  condyle.  In  the  latter  situation  the  displacement  is  peculiar, 
the  condyle  on  the  injured  side  being  drawn  forwards  and  in- 
wards by  the  external  pterygoid  muscle  of  that  side,  while  the 
rest  of  the  jaw  is  tilted  over  towards  the  injured  side  by  the  ac- 
tion of  the  opposite  external  pterygoid,  which  is  thus  left  unop- 
posed. This  sign  is  of  some  unportance  in  distinguishing  such  a 
fracture  from  a  partial  dislocation,  in  which  the  jaw  is  drawn  over 
to  the  side  opposite  the  dislocation.  Signs. — The  common  form 
of  fracture  may  be  readily  distinguished  by  pain  on  mastication, 
dribbling  of  saliva,  some  irregularity  in  the  line  of  the  teeth,  un- 
natural mobility  of  the  fragments,  crepitus,  and  a  rent  in  the 
mucous  membrane  over  the  fracture.  Fracture  through  the 
angle  may  be  detected  by  crepitus  and  by  slight  mobility  of  the 


312 


INJURIES   OF   REGIONS. 


Fig.  117. 


Gutta-percha  splint  for 
fractured  jaw.  (Bry- 
ant's Surgery.) 


Fig.  118. 


fragments  on  firmly  grasping  the  ascending  ramus  and  body  of 
the  jaw.  Fracture  through  the  neck  may  be  known  by  the 
peculiar  displacement  before  alluded  to,  and  perhaps  by  crepitus 
on  manipulation.  Treatment. — The  parts  should  be  placed  in 
apposition  and  kept  at  perfect  rest.  This  can  usually  be  done  by 
a  gutta-percha  splint  moulded  to  the  chin 
(Fig.  117),  and  secured  by  a  four-tailed 
bandage  (Fig.  120).  All  movements  of  the 
jaw  must  be  avoided,  the  patient  being  fed 
on  slops  introduced  either  behind  the  last 
molar  tooth  or  through  any  space  left  avail- 
able by  the  loss  of  a  tooth.  In  placing  the 
parts  in  apposition  some  difficulty  may  be 
experienced  in  consequence  of  a  displaced 
tooth  having  slipped  between  the  fragments. 
If  the  parts  cannot  be  kept  in  place  by  the 
simple  sphnt  above  mentioned,  they  must  be 
secured  either  by  drilling  the  fragments  and 
wiring  them  together,  or  by  means  of  the 
dental  splint  shown  in  the  accompanying 
drawing  (Fig.  118).  This  splint  consists  of 
a  wire  frame  fitted  round  the  back  and  front 
of  the  teeth,  and  further  secured  by  trans- 
verse wires  between  the  teeth.  One  of  the 
more  elaborate,  so-called  interdental  spHnts, 
may  at  times  be  found  necessary.  Union  is 
usually  accomplished  in  four  or  five  weeks. 

Dislocation  of  the  lower  jaw. — This  ac- 
cident may  sometimes  result  from  a  fall  or 
blow  upon  the  chin  with  the  mouth  open,  but  more  frequently 
occurs  from  spasmodic  action  of  the  external  pterygoid  muscles 
during  yawning.  When  both  condyles  are  displaced,  the  dislo- 
cation is  said  to  be  complete  ;  when  only  one  is  displaced,  in- 
complete. Nature  of  disp/aceinent. — The  condyle  with  the  in- 
terarticular  cartilage  is  drawn  over  the  eminentia  articularis  into 
the  zygomatic  fossa,  where  it  is  firmly  held  by  the  contraction  of 
the  internal  pterygoid,  masseter  and  temporal  muscles.  Signs. — 
The  mouth  is  widely  open  and  cannot  be  closed  by  any  voluntary 
effort  of  the  patient,  and  the  saliva  constantly  dribbles  away.  In 
complete  dislocation,  the  symphysis  remains  in  the  middle  line, 
and  an  unnatural  hollow  is  left  behind  each  condyle.  If  the  dis- 
location is  partial,  the  sym[)hysis  is  carried  over  to  the  opposite 
side,  and  the  hollow  is  felt  only  behind  the  dislocated  condyle. 
Treatment. — The  indications  are  to  overcome  the  contracted 
muscles,  and  so  allow  the  displaced  condyle  or  condyles  to  be 


Dental  splint  applied. 


SUBLUXATKJN    OF   THE    JAW. 


353 


Mechanism  of  reduction  of  a  dis- 
located jaw.  F.  Cork  acting 
as  fulcrum.  The  dotted  lines 
represent  the  masseter  and 
temporal  muscles — the  weighi 
to  he  overcome  by  the  hand  or 
power. 


drawn  by  the  temporal  and  deep  fibres  of  the  masseter,  the  re- 
tractors of  the  jaw,  over  the  eminentia  articularis  into  their 
sockets.  A  cork,  or  the  thumbs,  wrapped  in  a  towel  to  avoid 
being  bitten,  should  be  placed  between  the  last  molar  teeth  of 
the  upper  and  lower  jaw  on  each  side,  to  act  as  a  fulcrum  whilst 
pressure  is  made  in  an  upward  direction 
on  the  symphysis  by  the  Surgeon's  hands 
on  the  principle  of  a  lever  of  the  first 
order  (Fig.  119).  Whilst  the  symphysis 
is  thus  pushed  upwards  the  condyle  is 
drawn  downwards,  the  weight,  repre- 
sented by  the  contracted  muscles,  being 
gradually  overcome.  As  soon  as  the 
condvle  is  clear  of  the  eminentia  articu- 
laris it  is  drawn  back  into  its  place  with 
a  snap  by  the  fibres  of  the  retractor 
muscles.  At  times,  in  consequence  it 
would  appear  of  the  coronoid  process 
being  wedged  against  the  zygoma,  re- 
duction cannot  be  effected  in  this  way. 
Downward  and  backward  pressure  by  the 
protected  thumbs  will  then  generally 
succeed.  A  four-tailed  bandage  (Fig. 
120)  should  be  worn  for  a  fortnight  to 
prevent  re  dislocation,  which  is  very 
liable  to  happen. 

The  term  subluxation  of  the  jaw  is 
applied  by  some  to  a  displacement  of 
the  condyle  from  the  interarticular  car- 
tilage ;  by  others  to  an  unnatural  slipping 
forwards  of  the  interarticular  cartilage 
on  the  eminentia  articularis,  in  conse- 
quence of  rupture  or  elongation  of  the 
ligaments.  The  latter  condition  is  most 
frequently  met  with  in  delicate  young 
people.  The  condyle  catches,  and  the 
mouth  cannot  be  closed  for  a  second  or 
two,  but  it  can  generally  be  replaced  by 
the  patient's  voluntary  efforts  with  a 
distinct  snap,  l^ieaiment. — If  counter-irritation  and  tonics  do 
not  succeed,  the  joint  may  be  opened  and  the  cartilage  secured  in 
position  by  sutures. 

15* 


Fig.  120. 


The    four-tailed     bandage     ap- 
plied.    (Bryant's  Surgery). 


354  INJT-'RIES    OF    REGIONS. 

INJURIES  OF  THE  NECK,  INCLUDING  THE  ENTRANCE  OF  FOREIGN  BODIES 
INJO  THE  PHARYNX,  OESOPHAGUS  AND  AIR-PASSAGES. 

Wounds  of  the  neck. — Superficial  wounds  call  for  no  special 
comment.  Our  attention  here  need  only  be  given  to  wounds  of 
the  front  of  the  neck,  which  are  generally  inflicted  either  with 
homicidal  or  suicidal  intent.  Such  wounds  are  usually  of  the  in- 
cised variety,  more  rarely  punctured.  They  may  be  situated  any- 
where between  the  lower  jaw  and  the  top  of  the  sternum,  but  are 
more  common  in  the  laryngeal  region,  especially  through  the 
thyro-hyoid  membrane.  Suicidal  wounds  are  generally  made 
obliquely  from  left  to  right  and  from  above  downwards,  but  may 
be  transverse,  and  are  commonly  deeper  on  the  left  than  on  the 
right  side.  These  facts  are  explained  by  the  suicide  generally 
using  the  right  hand,  and  becoming  less  determined  as  he  pro- 
ceeds. There  is  usually  but  one  gash,  but  there  may  be  several ; 
and  again  the  gash  may  be  superficial,  or  it  may  be  deep,  even 
extending  to  the  s])ine.  The  structures  involved  will  depend  upon 
the  situation,  depth  and  extent  of  the  wound.  Thus,  i.  When 
the  wound  is  made  above  the  hyoid  bone,  the  tongue  may  be 
severed,  and  the  muscles  that  depress  the  jaw  and  elevate  the 
hyoid  bone  divided,  together  with  the  lingual  or  facial  arteries  and 
hypoglossal  nerve.  Such  a  wound  will  gape  widely,  and  may 
open  into  the  mouth,  and  food  and  saliva  then  escape  freely 
through  it.  2.  When  the  wound  is  through  the  thyro-hyoid 
membrane,  the  pharynx  will  be  opened,  and  the  epiglottis, 
aryejjiglottidean  folds  or  arytenoid  cartilages,  the  superior  thyroid 
and  lingual  arteries,  and  the  superior  laryngeal  nerve  may  be  cut 
through.  The  wound  gapes  less  than  in  the  preceding  situation, 
but  allows  of  the  escape  of  food  and  saliva.  There  is  usually  great 
difficulty  in  swallowing.  3.  When  the  wound  is  through  the 
cartilages,  the  vocal  cords  and  one  or  other  of  the  intrinsic 
laryngeal  muscles  may  be  divided,  with  consequent  loss  of  voice  ; 
the  cartilages  themselves,  moreover,  may  be  variously  disjjlaced. 
There  is  as  a  rule  but  little  haemorrhage.  4.  When  the  wound  is 
made  below  the  cricoid  cartilage,  the  depressor  muscles  of  the 
larynx,  the  inferior  or  superior  thyroid  artery,  and  the  thyroid  and 
anterior  jugular  veins  may  be  wounded,  the  trachea  partly  or  en- 
tirely cut  across,  and  even  the  oesoj^hagus  implicateci. 

Wherever  the  wound  is  situated,  the  carotid  arteries  generally 
escape,  owing  to  the  resistance  of  the  cartilages  of  the  larynx,  the 
deep  situation  of  the  carotids,  and  the  contraction  of  the  sterno- 
mastoid  muscles. 

Daivj^ers. —  The  i)nmc(liate  (hungers  are — i .  1  hemorrhage.  When 
the  carotid  artery  or  jugular  vein  is  wounded,  death  is  generally, 
though  not  invariably,  instantaneous ;  but    even  when  no  large 


CONTUSION    OF   THE    LAR\^X.  355 

vessel  is  implicated,  death  before  help  is  obtained  is  frequent  from 
haemorrhage  from  some  of  the  arteries  above  mentioned,  the  ex- 
ternal jugular  vein,  etc.  2.  Obstruction  to  respiration  in  conse- 
quence of  {a)  the  blood  entering  the  air-passages  in  larger  quanti- 
ties than  the  patient  can  cough  up;  {b)  the  lolling  back  of  the 
tongue  over  the  glottis  ;  (<:)  the  displacement  of  the  cartilages ; 
(//)  the  separation  of  the  divided  portions  of  the  trachea.  3. 
Entrance  of  air  into  the  veins  is  also  an  occasional  danger.  The 
subsequent  dangers  are — i.  Qidematous  laryngitis;  2.  Bronchitis 
and  broncho-pneumonia  ;  3.  Inflammation  and  suppuration  of  the 
loose  tissues  of  the  neck,  even  extending  to  the  mediastinum  or 
pleura ;  and  still  later,  4.  Obstruction  of  the  air-passages  with  in- 
creasmg  dyspnoea  or  loss  of  voice  from  («)  constriction  during 
cicatrization,  or  {b)  formation  of  prominent  granulations,  and  5, 
(Esophageal  or  tracheal  fistula. 

Treatment. — The  haemorrhage  must  be  arrested ;  the  air- 
passages  cleared  if  obstructed  with  blood,  by  suction  if  necessary, 
and  artificial  respiration  resorted  to  if  the  patient  has  already 
ceased  to  breathe.  If  the  tongue  or  epiglottis  is  divided,  it  must 
be  fixed  by  sutures,  or  if  a  portion  of  the  epiglottis  is  loose  it  may 
be  cut  off.  The  wound,  unless  quite  superficial,  should  not  as  a 
rule  be  approximated  by  suture  or  strapping,  but  by  position,  the 
patient  being  propped  up  by  pillows  and  the  head  bent  forwards. 
The  cartilages  of  the  larynx,  if  displaced,  may  be  brought  together 
by  suture,  as  may  also  the  trachea  if  divided.  When  the  oesophagus 
is  wounded  the  edges  may  be  united  by  suturing  the  muscular 
coat,  the  mucous  membrane  being  turned  inwards,  and  the 
patient  fed  by  a  tube  passed  through  the  mouth  and  beyond  the 
wound,  or  at  first  entirely  by  the  rectum.  Tracheotomy  may 
have  to  be  performed  if  respiration  is  embarrassed  by  displace- 
ment of  the  laryngeal  cartilages  or  by  oedema  of  the  glottis. 
When  the  air-passages  are  opened,  the  precautions  described 
under  Tracheotomy  must  be  taken  to  prevent  lung  trouble.  Sup- 
puration must  be  watched  for,  and  free  exit  given  to  pus  as  soon 
as  detected. 

Contusion  of  the  larynx  may  be  caused  by  blows  or  kicks  of 
all  kinds  and  manual  compression,  as  in  garrotting.  Symptoms. — 
Pain,  especially  on  handling,  localized  swelling  or  ecchymosis, 
alteration  or  loss  of  voice,  and  slight  haemoptysis  when  the  mucous 
membrane  is  lacerated.  Unless  there  is  much  bleeding  there  is 
usually  no  dyspnoea,  though  this  may  subsequently  be  present 
should  spasm  or  oedema  of  the  glottis  supervene.  Severe  com- 
pression of  the  larynx  is  said  at  times  to  have  been  instantly  fatal 
from  spasm  of  the  glottis.  The  treatment  should  be  directed 
towards  allaying  pain  and  preventing  inflammation.     Thus,  a  lead 


356  INJURIES   OF   REGIONS. 

and  opium  lotion  or  an  ice-bag  may  be  applied  over  the  larynx 
and  all  attempts  at  speaking  prohibited.  Should  signs  of  oedema- 
tous  laryngitis  appear,  leeches,  followed  by  hot  fomentations,  may 
be  placed  over  the  thyroid  cartilage,  whilst  scarification  of  the 
glottis,  and  if  this  fails  and  suffocation  threatens,  intubation  of  the 
larynx  or  tracheotomy  must  be  performed. 

Subcutaneous  rupture  of  the  trachea  is  a  rare  accident,  but 
may  be  caused  by  any  violence  applied  to  the  neck.  It  is  at- 
tended by  emphysema  and  dyspnoea,  and  is  usually  rapidly  fatal. 
An  incision  should  be  made  in  the  middle  line  of  the  neck,  and 
an  attempt  made  to  draw  the  lower  end  of  the  trachea  to  the  sur- 
face, and  to  pass  in  a  tracheotomy  tube. 

Fracture  and  dislocation  of  the  hyoid  bone. — Fraciure  may 
be  produced  by  any  violence  applied  to  the  neck,  especially  a 
severe  grip.  The  line  of  fracture  is  usually  about  the  junction  of 
the  greater  cornu  with  the  body,  but  may  occur  in  any  situation. 
The  usual  signs  are  pain,  increased  on  handUng,  on  turning  the 
head,  and  on  moving  the  tongue  ;  dysphagia  or  inability  to  swal- 
low ;  hoarseness  or  aphonia ;  a  sense  of  suffocation  on  protruding 
the  tongue  ;  mobility  of  the  fragments  and  crepitus ;  sometimes 
cough  and  dyspnoea  ;  and  hsemoptysis  when  there  is  laceration  of 
the  mucous  membrane.  Treatment. — The  fragments  should  be 
replaced  by  the  forefinger  passed  through  the  mouth,  whilst  the 
fingers  of  the  other  hand  manipulate  the  bones  externally,  a  gag 
and  chloroform  being  usually  necessary.  The  parts  must  then  be 
kept  perfectly  quiet,  and  the  patient  fed  on  slops  passed  well  to 
the  back  of  the  tongue. 

What  has  been  described  as  dislocation  of  the  hyoid  bone  ap- 
pears rather  to  be  a  condition  of  the  parts  due  to  relaxation  of  the 
ligaments  attaching  the  thyroid  cartilage  to  the  hyoid  bone. 

Fracture  of  the  cartilages  of  the  larynx. — The  fracture 
may  extend  through  either  the  thyroid  or  the  cricoid  cartilage,  or 
through  both.  The  thyroid  alone  is  most  usually  fractured. 
Cause. — Direct  violence  applied  to  the  part,  such  as  a  blow  or 
fall,  or  compression  with  the  hand,  as  in  garrotting.  The  usual 
signs  are  pain,  increased  on  speaking,  on  swallowing,  and  on 
handling  ;  dyspnoea  ;  cough  ;  expectoration  of  frothy  blood,  and 
later,  when  inflammation  has  come  on,  of  offensive  pus ;  emphy- 
sema when  the  mucous  membrane  is  injured  ;  great  swelling  and 
ecchymosis  ;  and,  on  examination,  irregularity,  undue  prominence 
or  flattening  of  the  cartilages,  cre])itus,  and  preternatural  mo- 
bility. 

The  danger  to  be  apprehended  is  obstruction  to  the  respiration 
in  consequence  of — i,  displacement  of  a  portion  of  cartilage 
across  the  larynx ;  2,  spasm  of  the  glottis  from  irritation  of  the 


BURNS    AND    SCALDS.  357 

fragments ;  3,  entrance  of  blood  into  the  air-passages ;  4,  swell- 
ing from  sub- mucous  extravasation  of  blood  ;  5,  oedematous  lar- 
yngitis ;  and  6,  perichondrial  abscess  and  necrosis  of  the  cartilage. 
Treatment. — If  the  parts  are  fairly  in  apposition,  all  that  can  be 
done  is  to  steady  them  with  a  bandage  and  suitably-shaped  pads  of 
lint.  But  when  there  is  serious  displacement  with  perforation  of 
the  mucous  membrane,  as  evidenced  by  severe  dyspnoea,  and 
spitting  of  blood,  tracheotomy  should  be  at  once  performed,  as 
otherwise  the  patient  runs  an  imminent  risk  of  sudden  suffocation. 
An  attempt  may  then  be  made,  with  the  hand  manipulating  the 
cartilage  externally,  and  with  the  forefinger  of  the  other  hand  in 
the  pharynx,  to  rectify  the  displacement. 

Injuries  of  the  Pharynx  and  (Esophagus  from  within. 

Wounds  of  the  pharynx  are  not  infrequently  met  with  from 
falls  with  a  pipe,  stick,  etc.,  in  the  mouth.  They  may  be  attended 
by  severe  haemorrhage  when  the  lateral  walls  of  the  pharynx  are 
punctured,  either  immediately,  or  on  removing  the  inflicting  body, 
or  later,  from  a  portion  of  the  stick  or  pipe  being  broken  off  and 
remaining  as  a  foreign  body  in  the  wound  where  it  has  caused 
suppuration  and  ulceration  of  a  vessel. 

lyeatment. — Any  bleeding  vessel  seen  should  be  secured,  or 
faihng  this,  pressure  must  be  made  with  a  stick  wrapped  round 
with  lint,  or  solid  perchloride  of  iron  applied.  As  a  last  resource 
the  common  or  external  carotid  must  be  tied.  Should  a  foreign 
body  be  seen  in  the  wound,  it  should  not  be  removed  till  prepara- 
tions have  been  made  (as  for  tying  the  carotid)  to  effectually  ar- 
rest any  haemorrhage  which  might  follow  its  extraction. 

Injuries  of  the  cesophagus  may  be  inflicted  in  attempts  to 
remove  a  foreign  body  or  to  pass  an  oesophagus  bougie  ;  or  its 
walls  may  be  perforated  by  a  fish-bone,  etc.,  or  may  occasionally 
be  ruptured  during  vomiting.  Fatal  haemorrhage  from  the  aorta, 
and  perforation  of  the  pericardium,  pleura,  and  posterior  medias- 
tinum, followed  by  inflammation  and  death,  have  occasionally  re- 
sulted from  such  injuries.  Treatment. — Where  a  wound  is  sus- 
pected, the  patient  should  at  first  be  fed  entirely  by  the  rectum, 
and  subsequently  given  only  fluids  in  small  quantities,  so  as  to 
allow  the  wound  time  to  heal. 

Burns  and  scalds. — Burns  of  the  pharynx  occasionally  occur 
from  the  inhalation  of  flame,  as  in  a  gas  explosion  or  from  the 
clothes  taking  fire  ;  scalds  are  more  common,  especially  among 
the  children  of  the  poor,  from  drinking  boihng  water  or  inhaling 
steam  from  the  spout  of  a  tea-kettle.  In  neither  of  these  injuries 
is  the  cesophagus  as  a  rule  involved.  In  the  case  of  burns  the 
flame  sometimes  appears  to  be  drawn  through  the  larynx  into  the 


35 S  INJURIES    OF    REGIONS. 

trachea.  The  boiling  water  is  generally  ejected  from  the  mouth 
and  nose,  and  only  affects  the  entrance  of  the  larynx.  Both 
burns  and  scalds  owe  their  gravity  to  the  fact  that  they  are  fre- 
quently followed  by  oedematous  laryngitis.  The  scalded  and 
white  appearance  of  the  mucous  membrane  and  the  history  of 
the  case  generally  make  the  diagnosis  plain.  Treat?nent. — The 
patient  should  be  placed  in  bed  in  a  warm  room  and  carefully 
watched  for  signs  of  oedematous  laryngitis.  Should  such  super- 
vene, the  swollen  mucous  membrane  at  the  entrance  of  the  larynx 
may  be  scarified ;  but  if  this  does  not  at  once  reheve,  an 
O'Dwyer's  tube  should  be  placed  in  the  glottis,  or  tracheotomy 
performed.  In  the  slighter  cases  the  application  of  a  hot 
sponge  to  the  larynx,  the  administration  of  small  doses  of  anti- 
mony, tincture  of  aconite  or  calomel,  or  mercurial  inunction  may 
be  tried. 

Charring  and  other  chemical  lesions  from  drinking  corrosive 
liquids,  strong  acids,  or  alkalies,  are  not  uncommon.  The  effects 
vary  according  as  such  liquids  are  taken  intentionally  or  acci- 
dentally. In  the  former  case,  the  larynx  usually  completely  es- 
capes, whilst  the  mouth,  pharynx,  oesophagus,  and  stomach,  may 
be  extensively  injured.  In  the  latter  case,  the  fluid,  on  the  dis- 
covery of  the  mistake,  is  expelled  forcibly,  and  some  of  it  thereby 
generally  enters  the  larynx  and  nasal  cavities,  but  little  passes 
down  the  oesophagus.  Here,  as  in  burns  and  scalds,  the  chief 
danger  to  be  apprehended  is  cedematous  laryngitis.  For  an  ac- 
count of  the  effects  that  may  follow  swallowing  corrosive  fluids, 
the  reader  is  referred  to  a  work  on  Forensic  Medicine.  It  need 
only  be  remarked  here  that  should  the  patient  recover  from  the 
immediate  dangers,  he  may  subsequently  come  under  the  care  of 
the  Surgeon  for  stricture  of  the  oesophagus,  due  to  the  cicatriza- 
tion following  the  injury. 

Foreign  bodies  in  the  pharynx  and  oesophagus. — Fish-bones, 
coins,  false-tooth-plates,  and  portions  of  food,  are  the  bodies 
most  commonly  impacted  in  the  pharynx  and  oesophagus.  The 
situations  at  which  they  may  become  arrested,  vary  with  the 
nature  of  the  body.  Fish-bones,  pins,  and  the  like,  are  easily 
caught  in  the  loose  folds  about  the  tonsil  and  fauces,  or  may  be 
impacted  lengthwise  across  the  pharynx.  Larger  bodies,  as  false- 
tooth-plates,  coins,  etc.,  commonly  become  lodged  about  the  cri- 
coid cartilage.  The  symptoms  and  /yrrt://>'/(;7// vary  according  to 
the  nature  and  size  of  the  foreign  body.  A  large  portion  of  meat 
arrested  over  the  .entrance  of  the  larynx  will  give  rise  to  urgent 
symptoms  of  suffocation,  and  endeavors  should  be  made  to  re- 
move it  instantly  by  the  finger  plunged  into  the  throat.  If  this 
fails,  laryngotomy  should  be  done  at  once,  and  artificial  respira- 


FOREIGN    BODIES    IN    THE    PHARYNX. 


359 


tion  resorted  to  if  the  patient  has  already  ceased  to  breathe.  A 
fish-bone  or  pin  may  give  rise  to  pricking  sensation  with  difficulty 
or  pain  on  swallowing,  and  the  patient  will  often  be  able  to  indi- 
cate the  position  where  it  has  lodged.  A  search  should  be  made 
for  it  in  the  mouth  and  throat,  aided  by  the  laryngoscopic  mirror ; 
but  it  must  not  be  forgotten  that  the  symptoms  in  consequence 
of  the  body  having  scratched  the  mucous  membrane  may  persist 
even  after  it  has  been  dissolved  or  swallowed.  If  in  the  tonsil  or 
about  the  fauces,  it  may  be  removed  with  the  dressing  forceps,  or 
it  may  be  hooked  out  from  the  upper  part  of  the  pharynx  by  the 
finger  nail.  If  a  foreign  body  is  beyond  reach  of  the  finger,  an 
attempt  must  be  made  to  extract  it  by  pharyngeal  forceps  (Fig. 
i2i)  or  by  some  of  the  various  forms  of  coin-catchers  (Fig.  122), 
or  the  expanding  horse-hair  extractor   (Fig.   123).     If,  after  a 

Fig.  121. 


Pharyngeal  forceps. 
Fig.  122. 


Coin-catcher  and  sponge  probang. 
Fig.  123. 

E.xpanding  horse-hair  extractor. 


thorough  trial,  with  the  patient  under  chloroform,  these  means 
fail,  pharyngotomy  must  be  performed,  and  the  body  removed 
through  the  opening  in  the  neck.  \¥hen  situated  lower  down 
the  oesophagus,  'and  it  cannot  be  extracted  by  gentle  means, 
it  had  better  be  left  alone  in  the  hope  that  it  may  become 
loosened  in  a  day  or  two  by  ulceration,  and  be  expelled  or  passed 
down  into  the  stomach.  Should  this  not  occur,  an  endeavor  may 
again  be  made  to  extract  it,  or  to  push  it  onwards  into  the 
stomach  with  the  sponge  probang  (Fig.  123).  In  these  manipula- 
tions the  greatest  care  must  be  taken,  as  if  the  body  is  sharp  the 
oesophagus  iTiay  easily  be  lacerated.     Recently  it  has  been  shown 


360  INJURIES   OF   REGIONS. 

that  the  cesophagiis  may  be  reached  as  it  lies  in  the  posterioi 
mediastinum  by  cutting  vertically  midway  between  the  scapula 
and  spine,  turning  in  the  ilio-costalis,  and  resecting  a  portion  of 
the  third,  fourth  and  fifth  ribs.  When  the  foreign  body  has  been 
pushed  into  the  stomach,  the  patient  should  be  fed  on  oatmeal 
porridge,  and  made  to  swallow  portions  of  hair,  and  the  like,  in 
the  hope  that  the  body,  if  angular,  may  become  surrounded  by 
this  soft  material  and  travel  through  the  intestines  without  injur- 
ing them.  Should  it  be  too  large  to  pass  the  pyloric  valve,  gas- 
trotomy  is  the  only  resource. 

FoRKiGN  BODIES  IN  THE  AIR  PASSAGES. — A  foreign  body  may  be- 
come lodged  in  the  larynx,  the  trachea,  or  in  one  of  the  bronchi. 

Foreign  bodies  in  the  larynx. — A  foreign  body  may  be  lodged 
above,  IdcIow  or  between  the  vocal  cords,  or  in  the  ventricles. 
When  a  voluminous  body,  as  a  piece  of  meat,  becomes  impacted 
at  the  entrance  of  the  larynx,  it  may  block  up  the  passage,  causing 
instant  suffocation.  Smaller  bodies,  wherever  situated,  may  also 
cause  fatal  dyspnoea  by  setting  up  reflex  spasm  of  the  muscles  of 
the  glottis ;  though  in  some  cases  a  foreign  body,  such  as  a  tooth- 
plate,  may  be  so  lodged  between  the  cords  as  to  prevent  them 
closing.  A  foreign  body  in  the  ventricle  may  cause  the  same 
urgent  symptoms.  At  other  times  the  foreign  body  may  give  rise 
to  severe,  but  not  fatal,  attacks  of  dyspnoea  and  spasmodic  cough, 
though  if  not  removed,  inflammation  and  oedema  will  probably  be 
set  up  and  the  patient  ultimately  succumb.  Treatment. — Where 
the  symptoms  are  urgent  and  the  body  cannot  be  removed  by  the 
finger,  instant  laryngotomy  should  be  performed.  But  when  less 
urgent,  a  deliberate  attempt  should  be  made  to  remove  it  by  means 
of  laryngeal  forceps  aided  by  the  laryngoscope.  Sometimes,  where 
extraction  would  be  otherwise  impossible,  this  may  be  accom- 
plished by  cutting  the  body  in  two  by  the  use  of  the  laryngeal 
cutting-pliers.  These  means  having  failed,  an  external  operation 
must  be  undertaken.  Thus,  when  the  foreign  body  is  above  the 
cords,  it  may  be  removed  by  sub-hyoid  pharyngotomy  ;  when  be- 
tween the  cords  or  in  the  ventricle,  by  thyrotomy  ;  when  below 
the  cords,  by  laryngo-tracheotomy  or  tracheotomy,  the  forceps  in 
the  last  instance  being  passed  up  through  the  wound  in  the 
trachea. 

Foreign  bodies  in  the  trachea  and  bronchi. — Small  objects  such 
as  coins,  buttons,  orange-pips  and  fruit  stones  are  liable  to  be 
drawn  into  the  trachea  during  a  sudden  inspiration,  while  the 
patient  is  swallowing  or  is  holding  such  in  his  mouth.  The  acci- 
dent is  most  common  in  children.  The  foreign  body  may  remain 
free,  or  become  impacted  either  in  the  trachea  or  a  bronchus 
(Fig.  124).     It  is  usually  .said  to  most  frequendy  enter  the  right 


FORETGN   BODIES   IN   THE   AIR   PASSAGES. 


361 


Fig.  124. 


bronchus,  that  being  the  larger,  and  the  spur-like  projection  at 
the  bifurcation  of  the  trachea  directing  it  that  way ;  but  the  left 
is  the  more  direct  route,  and  the  direction  it  takes  would  seem  to 
depend  in  great  part  on  the  shape  and  size  of  the  foreign  body. 
Thus  an  elongated  body  as  the  metal  cap  of  a  cedar  pencil  would 
probably  enter  the  left — a  rounded  body,  as  a  coin,  the  right 
bronchus.  The  symptoms  vary  somewhat,  according  as  the  body 
is  free  or  impacted,  light  or  heavy.  When  it  is  free  and  light,  and, 
as  is  usually  the  case,  has  fallen  into  one  of  the  bronchi,  there 
will  be  sudden  and  paroxysmal  attacks  of  suffocative  cough  and 
dyspnoea,  in  consequence  of  the  foreign 
body  being  driven  upwards  against  the 
glottis,  which  then  closes  spasmodically. 
On  listening  over  the  trachea  it  may  be 
heard  to  strike  the  cords,  whilst  a  whist- 
ling sound  may  sometimes  be  detected  as 
it  passes  up  and  down.  During  the  in- 
tervals of  the  cough  and  dyspnoea,  whilst 
the  body  is  at  rest  in  the  bronchus,  as  is 
'also  the  case  when  it  is  permanently  im- 
pacted in  it,  there  will  be  an  absence  of 
the  breathing  sounds  over  the  whole  or 
part  of  the  lung  on  that  side,  according  as 
the  main  bronchus  or  one  of  the  secondary 
bronchi  is  obstructed  \  the  resonance, 
however,  will  be  normal  or  dull  in  places, 
according  to  the  position  and  nature  of 
the  foreign  body.  If  any  air  can  pass  the 
obstructing  body,  bronchial  or  sibilant 
sounds  may  be  heard,  due  in  part  to  the 
bronchitis  set  up  by  it.  Over  the  opposite  lung  puerile  breathing 
may  be  detected.  When  the  foreign  body  is  heavy  and  of  a 
rounded  shape,  it  may  act  as  a  ball-valve,  /.  e.,  it  may  allow  air 
from  the  lung  to  be  forced  past  it  during  expiration,  but  then  fall 
back  into  a  narrower  part  of  the  bronchus,  and  so  prevent  air  en- 
tering during  inspiration.  In  this  way  collapse  of  the  lung  is 
brought  about.  If  the  foreign  body  is  not  removed,  or  does  not 
escape  spontaneously,  sudden  death  may  occur  during  an  attack 
of  spasmodic  dyspnoea  ;  or  it  may  set  up  bronchitis,  pneumonia, 
or  gangrene  or  abscess  of  the  lung.  At  other  times  it  induces 
more  chronic  changes,  such  as  phthisis,  or  it  may  become  en- 
cysted and  no  harm  follow.  In  rare  instances  it  may  make  its 
way  out  through  the  chest-walls  by  perforation  or  ulceration. 

Treatment. — The  patient  should  be  inverted.     Before  doing 
this,  however,  everything  should  be  in  readiness  for  instant  trach- 
16 


Foreign  body  in  the  right 
bronchus.  The  trachea  is 
opened  from  the  front.  (St. 
Bartholomew's  Hos  p  i  t  a  1 
Museum.) 


362  "  INJURIES   OF   REGIONS. 

eotomy,  in  case  the  foreign  body  becomes  lodged  in  the  larynx 
and  gives  rise  to  spasm  of  the  glottis.  Children  may  be  held  up 
by  the  legs,  but  for  adults  some  special  contrivance  may  be  nec- 
essary, as,  for  instance,  Brunei's  table.  Inversion  failing,  trach- 
eotomy should  be  peiformed,  as  the  patient  is  in  danger  of  suf- 
focation at  any  instant.  On  opening  the  trachea,  should  the 
foreign  body  not  be  expelled  at  once,  either  through  the  wound 
or,  as  sometimes  happens,  through  the  mouth,  the  patient  may  be 
again  inverted,  or  search  made  for  it  through  the  wound  with 
tracheal  forceps,  wire  variously  bent,  etc.  These  means  failing, 
the  tracheotomy  wound  must  be  kept  open  to  allow  of  future  trials 
being  made  if  the  foreign  body  is  not  expelled  during  the  interval. 

Pharvngotomy  or  CEsophagotomy  is  the  operation  of  opening 
the  lower  part  of  the  pharynx  or  upper  part  of  the  oesophagus 
for  the  purpose  of  removing  a  foreign  body.  As  the  oesophagus 
inclines  to  the  left,  the  operation  by  choice  is  done  on  that  side, 
unless  the  body  be  felt  distinctly  on  the  right  side.  Make  an 
incision  about  four  inches  long,  having  its  centre  opposite  the 
cricoid  cartilage,  parallel  to  the  sterno-mastoid,  over  the  inter- 
space between  the  great  vessels  and  the  larynx.  Divide  the  pla- 
tysma  and  deep  fascia  ;  draw  the  sterno-mastoid  outwards,  and  the 
sterno-hyoid  and  sterno-thyroid  inwards;  and  divide  the  omo- 
hyoid if  in  the  way.  Gently  draw  the  larynx  and  trachea  across 
the  middle  hne  in  order  to  separate  them  from  the  great  vessels; 
and  then  open  the  pharynx  or  oesophagus,  as  the  case  may  be,  by 
cutting  on  the  foreign  body  if  felt,  or  on  the  point  of  a  sound 
passed  through  the  mouth  and  made  to  project  in  the  wound. 
Avoid  injuring  the  superior  and  inferior  thyroid  arteries  and  the 
recurrent  laryngeal  nerve.  The  incision  in  the  oesophagus  should 
be  united  by  sutures  passed  through  the  muscular  coat  only.  The 
external  wound  should  then  be  closed,  drained  and  dressed  anti- 
septically.  The  patient  should  be  fed  entirely  by  the  rectum  for 
some  days  after  the  operation,  or  by  a  tube  passed  down  the 
oesophagus  and  retained  in  situ. 

Opening  the  oesophagus  in  the  posterior  mediastinum  has  re- 
cently been  proi)osed  for  the  extraction  of  a  foreign  body  in  the 
thoracic  portion  of  the  tube.     (See  Stricture  of  Oesophagus.) 

INJURIES  of  the  15ACK. 

Sprains  of  the  spine  are  exceedingly  common,  and  may  be 
caused  by  any  violent  twist  or  bend  of  the  back.  '\\\&  pathology 
of  these  injuries  is  hardly  known.  'J'hey  are  said  to  depend  upon 
a  partial  tearing  or  rupture  of  the  spinal  ligaments,  muscles  or 
fasciae,  but  oi)portunities  for  verifying  this  statement  seldom  oc- 


DISLOCATION   AND    FRACTURE.  363 

cur.  Sprains  of  the  back  may  be  complicated  by  concussion  of 
the  spinal  cord,  extravasation  of  blood  in  the  subcutaneous  tissue, 
er  contusion  or  rupture  of  the  kidney.  They  mny,  moreover,  be 
folljwed  by  inflammation  of  the  inteivertebral  joints  and  fibrous 
tissue  about  the  spine;  the  inflammation  may  then  at  times 
spread  to  the  membranes  and  cord,  or  be  the  starting-point  of 
vertebral  caries.  Symptoms. — The  patient  usually  complains  of 
having  ricked  his  back,  /.  e.,  of  severe  pain  localized  to  one  spot, 
commonly  the  lumbar  region,  and  mcreased  on  movement  and 
pressure.  On  examination  no  definite  injury  beyond,  perhaps, 
some  obscure  swelling  about  the  tender  spot,  or  more  rarely  blood- 
extravasation,  is  discoverable.  In  the  cervical  region  a  sprain 
may  sometimes  simulate  a  dislocation,  the  pain  causing  the 
patient  to  hold  the  head  in  a  fixed  and  one-sided  position,  thus 
rendering  the  transverse  processes  on  one  side  of  the  neck  more 
prominent  than  natural.  In  the  lumbar  region  a  severe  sprain 
may  sometimes  simulate  an  injury  of  the  spinal  cord,  inasmuch 
as  the  patient  may  complain  of  vi^eakness  of  the  legs  or  inability 
to  move  them,  or  may  even  experience  some  difficulty  in  defae- 
cating  or  passing  urine.  It  will  be  found,  however,  that  in  these 
cases  no  true  paralysis  exists,  but  that  the  apparent  loss  of  power 
is  due  to  the  pain  which  is  mduced  on  attempts  at  movement. 
The  tt'eatment  consists  in  rest,  and  the  application  of  hot  fomen- 
tations to  relieve  pain,  and  later  of  stimulating  liniments.  In 
severe  cases  the  patient  should  be  kept  in  bed  for  a  week  or  so, 
and  subsequently  shampooing,  massage  and  galvanism  may  have 
to  be  em.plcyed  to  overcome  the  pain  and  stiffness  which  often 
last  for  some  time. 

Wounds  of  the  spinal* membranes  and  cord  may  be  inflicted 
by  stabs  in  the  back,  falls  on  sharp  bodies,  etc.  When  the  mem- 
branes alone  are  wounded,  there  may  at  first  be  no  signs  except 
perhaps  an  escape  of  ceiebro-spinal  fluid;  but  later,  should  in- 
flammation be  set  up,  there  will  be  the  usual  signs  of  spinal  men- 
ingitis. A  wound  of  the  spinal  nerves  may  be  known  by  paraly- 
sis of  the  parts  which  they  sup|)ly ;  a  wound  of  the  cord,  by  par- 
alysis of  the  parts  below  the  seat  of  mjury.  When  division  is 
complete  the  knee-jerk  is  quite  lict,  when  incomplete  the  knee- 
jerk  may  be  exaggerated.  The  /,  ^^/w,?;// consists  in  placing  the 
patient  at  absolute  rest,  and  in  keeping  the  wound  perfectly 
aseptic  to  prevent  inflammaucn  ;  but  if  the  cord  has  been  di- 
vided, permanent  paialybis  will  necessarily  ensue.  Should  in- 
flammation occur,  the  appropiiate  remedies  for  meningitis  must 
be  administered.     (See  Work  on  Medicine.) 

Dislocation  and  feaciukk. — Li'docaticn  of  the  spine  without 
fracture  is  exceedingly  rare  ;  indeed,  except  in  the  cervical  region, 


3^4 


INJURIES   OF   REGIONS. 


Fig.  125. 


it  is  said  never  to  occur.  Fracture  unaccompanied  by  dislocation 
is  also  uncommon  ;  but  uncomplicated  cases  of  fracture  of  the 
spinous  process  and  laminae,  and  more  rarely  of  the  transverse  antl 
articular  processes,  are  sometimes  met  with.  In  the  majority  of 
cases  fracture  and  dislocation  are  combined.  Thus,  usually  there 
is  fracture  of  the  body  and  articular  processes  of  one  or  more  of 
vertebrae,  with  dislocation  of  the  whole  of  the  spine  above  the 
seat  of  injury  from  the  spine  below.  This  common  form  of  injury 
is  in  the  context  spoken  of  2&  fracture-dislocation. 

Fraciure-Dislocation.  Causes. — It  is  either  the  result  of 
direct  violence  applied  to  the  spine,  or  of  indirect  violence,  as  a 
fall  upon  the  head.  i.  When  the  result  of  ^///rr/ violence,  which 
can  only  be  applied  to  the  posterior  part  of  the  spine,  one  or  more 
of  the  spinous  processes  may  be  detached 
without  implicating  the  vertebral  canal. 
When  the  violence  is  very  great,  as  in  a 
fall  from  a  height  on  the  back  across  a 
beam  or  rail,  or  a  severe  blow  as  from  a 
crane,  the  spine  is  bent  violently  back- 
wards, tearing  asunder  the  structures 
forming  the  anterior  segment  of  the 
column,  and  crushing  those  forming  the 
posterior.  Hence  the  vertebral  bodies 
are  generally  uninjured,  but  wrenched 
apart,  the  intervertebral  cartilages  are 
ruptured,  the  anterior  common  ligament 
is  torn,  and  the  arches  of  the  vertebrae 
and  the  articiilar  and  spinous  processes 
are  crushed.  The  vertebrae  above  the 
injury  are  dislocated  forwards,  as  the 
articular  processes  being  fractured  and 
the  intervertebral  cartilages  torn,  nothing  remains  to  keep  them 
in  position.  2.  In  fracture  from  indirect  v\o\enct  (Fig.  125),  such 
as  may  be  received  in  a  fall  from  a  height  upon  the  head,  or 
catching  the  head  whilst  passing  under  an  arch,  or  from  a  weight 
frilling  upon  the  head  or  shoulders,  the  spine  is  bent  violently  for- 
wards, crushing  the  anterior  j)art  of  the  column  and  tearing  the 
posterior  asunder.  Here  one  or  more  of  the  bodies  and  inter- 
vertebral cartilages  are  crushed  between  the  vertebrcC  above  and 
the  vertebrae  below,  one  of  the  fragments  of  the  fractured  body 
being  frccpiently  driven  backwards  into  the  vertebral  canal,  whilst 
the  arches  and  the  spinous  and  articular  ])rocesses  are  wrenched 
asunder.  Fracture  of  the  sternum  is  occasionally  combined  with 
this  injury,  in  consequence,  it  is  said,  of  the  chin  coming  into 
violent  contact  with  the  sternum  as  the  spine  is  doubled  forwards. 


Fracture-dislocation  of  the 
spine.  (.St.  Bartholomew's 
Hospital  Museum.) 


FRACTURE    DISLOCATION.  365 

Condition  of  the  spinal  cord. — The  importance  of  fracture-dis- 
location of  the  spine  lies  not  so  much  in  the  fact  that  the  vertebrae 
are  fractured  as  that  the  cord  is  generally  injured.  When  the 
vertebrse  are  not  displaced,  the  cord  may  at  times  altogether 
escape.  More  commonly,  however,  it  is  compressed,  or,  perhaps, 
completely  divided,  or  again  so  bruised  that  it  rapidly  undergoes 
inflammatory  softening.  When  the  injury  is  situated  below  the 
second  lumbar  vertebrce,  the  cord  necessarily  escapes  as  it 
terminates  at  that  spot,  but  the  nerves  of  the  cauda  eqaina  may 
then  be  injured. 

Signs  and  symptoms. — The  local  signs  are  often  but  little 
marked.  There  may  be  pain  at  the  seat  of  injury,  or  some  in- 
equality in  the  spinous  processes ;  but  as  often  as  not  these  are 
absent.  The  general  signs  depend  upon  the  condition  of  the 
cord,  and  none  will  be  present  when  it  has  escaped  injury.  But 
when  it  is  compressed  or  crushed  there  will  be  paralysis  of  the 
parts  below,  more  or  less  complete  according  to  the  extent  of  the 
lesion.  Taking  as  an  example  a  case  of  fracture  in  the  lower  cer- 
vical or  upper  dorsal  region — the  most  common  situation — with 
severe  compression  or  crushing  of  the  cord,  there  will  be  paraly- 
sis of  both  motion  and  sensation  of  the  whole  of  the  parts  below 
the  seat  of  injury  {paraplegia),  and  perhaps  a  zone  of  hyper- 
sesthesia  immediately  above  the  injured  part.  The  intercostal 
muscles  being  paralyzed,  respiration  can  only  be  carried  on  by 
the  diaphragm,  this  muscle  receiving  its  nerve-supply  through  the 
phrenics  which  are  given  off  above  the  seat  of  injury.  Hence, 
while  the  chest  is  motionless,  the  abdomen  rises  and  falls  during 
respiration.  The  bladder  and  rectum  and  their  respective 
sphincters  share  in  the  paralysis,  so  that  there  is  at  first  retention 
of  urine  and  faeces,  followed  by  passive  overflow  of  urine  as  the 
bladder  becomes  distended  and  will  hold  no  more,  and  by  invol- 
untary passage  of  fteces.  Priapism,  or  involuntary  erection  of  the 
penis,  is  frequently  present,  or  is  induced  by  the  use  of  the  cath- 
eter. The  temperature  varies ;  sometimes  it  may  be  lower  than 
normal,  but  often  it  is  considerably  raised,  even  reaching  as  high 
as  107°  shortly  before  death.  Consciousness,  unless  any  head- 
injury  has  been  received  at  the  same  time,  is  not  affected.  The 
reflexes  in  the  lower  limbs  are  usually  at  first  in  abeyance,  but 
may  return  if  the  patient  does  not  succumb  to  the  shock  of  the 
injury.  If  the  reflexes  remain  quite  lost  the  probabilities  are  that 
the  conducting  power  of  the  cord  has  been  completely  destroyed. 
If  they  return  it  is  a  sign  that  some  power  of  conductivity  is  left 
in  certain  portions  of  the  cord  at  the  seat  of  injury.  Death  oc- 
curs, as  a  rule,  from  twenty-four  hours  to  a  few  days  from  bron- 
chial trouble ;  but  the  patient,  if  the  fracture  is  in  the  upper 


366  IN7URIES    OF    REGIONS. 

dorsal  region,  may  linger  from  two  to  three  weeks.  The  second- 
ary troubles  which  are  then  generally  met  with  are  bed-sores  and 
chronic  cystitis,  i.  The  bed-sores  occur  in  situations  subjected 
to  pressure,  and  depend  in  great  part  on  the  congestion  and  low- 
ered vitality  of  the  tissues  induced  by  the  impairment  of  the 
nerve-influence  ;  but  they  may  also  to  some  extent  be  due  to  the 
soddening  of  the  part  with  the  urine  and  fceces,  from  which  it  is 
very  difficult  to  keep  the  patient  free.  2.  The  chronic  cystitis  is 
probably  also  due  in  part  to  impaired  neive  influence,  and  in  part 
to  slight  injury  in  the  passage  of  a  catheter,  or  to  the  introduction 
by  the  catheter  of  a  micro-org:ini>m — the  micrococcus  urese. 
The  urine,  which  is  at  first  acid,  hecoaies  amraoniacal  from  the 
conversion  of  the  urea  mto  c  rbonate  of  ammonia,  and  thick 
from  the  deposit  of  phosphates  and  the  presence  of  ropy  mucus. 
The  inflammation  may  then  extend  up  the  ureter  to  the  kidney, 
where  suppuration  of  the  pelvis  ar,d  substance  of  the  kidney 
{pye/o-nephritis)  may  be  set  up. 

Such  may  be  taken  as  a  typical  example  of  fracture  of  the  spine 
as  commonly  met  with  in  surgical  practice.  But  the  nature  and 
gravity  of  the  symptoms  will  depend  upon  the  situation  of  the 
fracture,  and  the  amount  of  injury  to  the  cord.  Thus  in  some 
cases  of  fracture  there  may  be  n  >  pirjlysis  ;  in  others  the  paraly- 
sis may  be  incomplete,  /.  <?.,  confined  to  loss  of  motion  only,  or  to 
paralysis  of  one  limb  or  one  group  of  muscles,  or  to  impairment 
of  sensation  over  some  limited  area.  Such  cases,  however,  are 
much  less  common  than  that  above  described. 

Causes  0/  Death. —  1.  When  the  fracture  is  above  the  fourth 
cervical  vertebra,  death  is  instantnneius  in  consequence  of  the 
severance  of  the  phrenic  nerves  from  the  respiratory  centre  in  the 
medulla.  2.  In  the  lower  cervical  vv  upper  dorsal  region,  death 
is  due  either  to  {a)  haemorrhage  in  the  cord  gradually  extending 
to  the  origin  of  the  phrenic  nerves,  or  {h)  a  low  form  of  bron- 
chitis  induced  partly  by  hypostitic  congestion,  partly  by  defective 
nerve-influence,  and  ])artly  by  inability  to  clear  the  lungs  effect- 
ually by  coughing  3.  Later,  death  is  commonly  due  to  exhaus- 
tion produced  by  {a)  the  sloughing  of  the  bed-sores,  or  {b)  the 
pyelonephr'tis,  inducetl  in  part  by  the  extension  of  cystitis  up  the 
ureters  to  the  kidney,  and  in  part  by  the  defective  nerve-influence 
on  the  kidney  structure. 

'Yhe.  proi^iwsis  will  flepend  in  great  measure  on  the  situation  of 
the  fracture  and  condition  of  the  cord.  'Ihus,  when  the  fracture 
is  /;/  i/ie  cervical  ret^io  11,  if  death  is  not  instantaneous,  the  i^atient 
may  survive  from  twelve  hours  to  two  or  three  days  ;  usually,  how- 
ever, death  occurs  in  about  twenty-four  hours.  In  the  upper 
dorsal  region  the  patient  may  linger  for  two  or  three  weeks.     In 


FRACTURE    DISLOCATION.  367 

the  lower  dorsal  region,  if  he  survive  the  period  at  which  the  in- 
flammatory troubles  commonly  occur,  he  may  recover,  remaining, 
however,  if  the  cord  is  severely  injured,  paraplegic.  In  the  lum- 
bar j-egion  he  may  recover,  with  perhaps  only  partial  paralysis  of 
one  or  other  of  the  lower  hmbs  or  of  a  certain  group  of  muscles, 
or  even  without  any  paralysis  whatever.  But  even  where  the  in- 
jury to  the  cord  has  been  so  high  as  to  cause  paralysis  of  the 
whole  body  below  the  neck,  patients  have  been  known  in  rare  in- 
stances to  live  for  several  months  or  even  years. 

Treatment. —  i.  In  cases  where  there  is  no  paralysis,  thus  show- 
ing that  the  cord  is  not  affected,  the  indication  is  to  keep  the 
fractured  spine  at  perfect  rest,  for  the  purpose  not  only  of  ob- 
taining union  of  the  fracture,  but  also  of  preventing  by  any  move- 
ment displacement  of  the  fragments  and  injury  of  the  cord.  2. 
In  the  more  common  cases,  where  there  is  paralysis,  showing 
that  the  cord  is  injured,  the  indications  are  to  remove  any  frag- 
ments that  may  be  compressing  the  cord,  and  subsequently  to 
keep  the  parts  at  rest  till  union  of  the  bones  has  occurred.  3. 
Where,  however,  as  is  too  frequently  the  case,  the  removal  of  the 
fragments  is  not  practicable,  or  the  cord  itself  has  been  crushed, 
all  that  can  be  done  is  to  endeavor  to  guard  against  the  formation 
of  bed-sores,  and  the'occurrence  of  chronic  cystitis  and  its  at- 
tendant evils.  Thus  the  patient  should  be  placed  upon  a  water- 
bed,  and  his  posture  gently  changed  from  time  to  time,  so  that 
pressure  may  not  be  continuously  made  on  one  part,  while  he 
must  be  kept  scrupulously  clean  and  dry,  and  free  from  urine  and 
faeces.  The  bowels  should  be  cleared,  if  necessary,  by  enemata, 
or  excessive  diarrhoea  controlled  by  morphia  suppositories  or 
starch  and  opium  injections.  Should  bed-sores  threaten,  the 
skm  should  be  hardened  by  sponging  with  rectified  spirit,  and 
dusted  with  oxide  of  zinc  and  starch  powder.  If  formed,  they 
should  be  dressed  with  mild  antiseptics,  iodoform,  balsam  of 
Peru,  etc.,  and  all  pressure  removed  from  the  surrounding  skin 
by  the  use  of  water  cushions.  To  prevent  cystitis  from  occurring 
a  soft  rubber  catheter,  thoroughly  cleansed  in  carbolic  acid  and 
dipped  in  carbolic  oil,  should  be  passed  twice  daily.  Should  the 
urine  become  alkaline  the  bladder  must  be  washed  out  with  some 
antiseptic  solution,  as  salol  (gr.  x  to  ^j)  or  boric  acid  (gr.  x  to 
.^j).  Extension  and  trephining  of  the  spine. — In  cases  where 
from  the  marked  inequality  of  the  spinous  process  there  is  a 
probabiHty  of  fragments  pressing  upon  the  cord,  a  cautious  at- 
tempt to  extend  the  spine  and  reduce  the  displaced  vertebrae 
may  be  made,  and  a  plaster-of-Paris  case  applied  during  the  ex- 
tension. In  some  instances  it  may  be  justifiable  to  trephine  the 
spine  {laminectomy)  for  the  purpose  of  removing  a  fragment  or 


368  INJURIES   OF   REGIONS. 

extravasated  blood  ;  but  space  will  not  permit  of  the  discussion  of 
this  interesting  question. 

Concussion  of  the  spinal  cord. — The  term  has  been  applied 
to  various  injuries  of  the  cord  received  in  railway  and  other  ac- 
cidents. It  ought,  however,  to  be  restricted  to  those  cases  in 
which  the  cord  is  merely  concussed  or  shaken  ;  and  the  other  in- 
juries, such  as  haemorrhage  into  its  substance  or  into  the  arach- 
noid, contusions,  and  lacerations,  all  of  which  have  been  included 
under  the  term  "  concussion,"  described  as  spinal  haemorrhage, 
laceration  of  the  spinal  cord,  etc.  Concussion  in  this  sense  is  one 
of  the  rarest  of  injuries,  and  need  not  detain  us  in  a  work  of  this 
character.  For  an  account  of  the  other  lesions,  and  the  very 
various,  pppaiently  anomalous,  and,  as  yet,  far  from  understood 
symptoms  which  may  attend  them,  and  which  are  generally 
classed  together  under  the  term  of  the  "railway  spine,"  a  larger 
work  must  be  consulted. 

injuries  of  the  chest. 
Injuries  of  the  Chest-ivalls. 

Contusions  may  be  produced  by  any  sort  of  violence  applied 
to  the  chest,  and  may  be  attended  with  lateration  or  rupture  of 
the  muscles,  or  with  extravasation  of  blood  into  the  tissues,  which, 
again,  may  be  followed  by  suppuration  and  abscess.  They  owe 
their  chief  importance,  however,  to  the  fact  that  they  may  be 
complicated  by  serious  injury  to  the  contained  viscera,  such  as 
contusion  or  laceration  of  the  pleura,  heart,  lung,  or  pericardium, 
or  rupture  of  a  large  vessel  in  the  mediastina. 

Fracture  of  ihe  ribs  is  a  very  common  accident.  Cause. — 
Generally  external  violence,  rarely  muscular  action,  i .  External 
violence  may  be — {a)' Direct,  such  as  the  kick  of  a  horse,  a  fall 
upon  the  edge  of  a  table,  etc.  The  fracture  then  occurs  at  the 
seat  of  injury,  the  fragments  being  driven  inwards,  occasionally 
injuring  the  thoracic,  or  more  rarely,  the  abdominal  viscera  ;  or 
{h)  Indirect,  as  the  severe  compression  of  the  chest  in  a  crowd. 
The  fracture  then  generally  occurs  about  the  angle  of  the  ribs, 
their  weakest  part,  and  several  bones  are  usually  broken.  2. 
Mnsciilar  action. — The  ribs  are  sometimes  broken  in  this  way 
during  violent  coughing,  or  from  straining  during  parturition. 

Complications. — Fractures  of  the  ribs  may  be  complicated  by 
an  external  wound  ;  a  wound  of  the  pleura  and  lung,  or  peri- 
cardium and  heart ;  laceration  of  a  blood-vessel,  as  an  intercostal 
artery ;  penetration  of  the  diaphragm  ;  and  more  rarely  by  per- 
foration of  the  peritoneum,  and  wound  of  the  liver  or  spleen. 
Hence   they  may  be    followed  by    emphysema,   pneumothorax, 


FRACTURE    OF    THE    STERNUM.  369 

hsemothorax,  haemoptysis,  hgemopericardium,  and  later  by  pleur- 
isy, pneumonia,  pericarditis,  or  peritonitis. 

State  of  the  parts. — Fracture  of  the  ribs  is  more  common  in 
the  old  than  in  the  young,  on  account  of  the  loss  of  elasticity  as 
age  advances.  Like  fractures  of  other  bones,  they  may  be  simple, 
compound,  or  comminuted.  The  middle  ribs  are  those  usually 
affected  ;  the  first  and  second  rib  being  protected  by  the  clavicle, 
and  the  eleventh  and  twelfth  being  movable,  are  not  often 
broken.  Fracture  of  the  upper  ribs  is  more  serious  than  fracture 
of  the  lower,  as  the  lung  is  more  liable  to  be  wounded. 

Signs. — Severe  stabbing  pain  is  felt  over  the  seat  of  fracture, 
and  is  increased  on  taking  a  deep  breath,  or  on  coughing.  On 
drawing  the  finger  along  the  rib,  some  irregularity  may  be  de- 
tected. Crepitus  is  usually  felt  on  placing  the  hand  flat  over  the 
fracture  while  the  patient  breathes  deeply,  or  it  may  be  heard  on 
listening  with  the  stethoscope.  Emphysema,  i.  e.,  a  crackling 
sensation,  something  like  rubbing  the  hair  between  the  fingers, 
may  at  times  be  felt  on  touching  the  part.  It  is  nearly  always 
due  to  a  wound  of  the  lung,  the  air  being  drawn  into  the  pleura 
through  the  visceral  layer  during  inspiration,  and  forced  through 
the  wound  in  the  parietal  layer  into  the  subcutaneous  tissue  dur- 
ing expiration. 

Treatment. — In  an  ordinary  case  the  injured  side  should  be 
strapped  with  adhesive  plaster,  so  as  to  control  the  respiration  on 
that  side  and  thus  place  the  fractured  rib  as  much  as  possible  at 
rest.  A  broad  bandage  in  addition  apphed  round  the  chest  often 
gives  relief.  When  several  ribs  are  broken  a  shield  of  gutta- 
percha may  be  moulded  to  the  chest-walls  and  strapped  on. 
Union  occurs  by  ensheathing  callus  in  three  or  four  weeks. 

Fracture  of  the  sternum  is  rare.  It  may  be  accompanied 
by  fracture  of  the  ribs  or  costal  cartilages,  separation  of  the  ribs 
from  their  cartilages,  and  sometimes  by  fracture  of  the  spine. 
Causes. — Direct  violence  ;  indirect  violence  in  consequence  of  a 
forcible  bend  of  the  body,  either  backward  or  forwards ;  very 
rarely,  muscular  action,  as  during  parturition. 

State  of  the  parts. — The  line  of  fracture  generally  runs  through 
the  gladiolus,  and  may  be  transverse,  obhque,  or  longitudinal,  the 
lower  fragment  usually  projecting  in  front  of  the  upper  ;  but  at 
times  the  gladiolus  is  separated  from  the  manubrium,  a  condition 
sometimes  spoken  of  as  dislocation  of  the  sternum.  The  chief 
signs  are  pain,  increased  on  deep  inspiration  and  coughing, 
irregularity  and  crepitus  at  the  seat  of  fracture,  and  emphysema 
if  the  lung  is  wounded.  The  fracture  may  be  complicated  by 
injury  of  any  of  the  thoracic  viscera,  or  by  hsemorrhage  or  sup- 
puration in  the  anterior  mediastinum.     Treatment. — Rest  on  the 


370  INJURIES    OF    REGIONS. 

back,  and  the  application  of  a  bandage,  if  it  can  be  borne,  round 
the  chest. 

Wounds  of  the  chest-walls  may  be  divided  into  the  pene- 
trating and  non-penetrating.  The  non-penetrating  are  of  no 
serious  consequence,  and  may  be  treated  hke  wounds  in  other 
situations.  The  penetrating  are  those  that  pass  through  the 
parietes  into  the  pleura,  pericardium,  or  mediastinum,  and  may 
be  complicated  by  a  wound  of  the  lung,  the  heart,  a  large  blood- 
vessel, an  intercostal  artery,  or  the  internal  mammary  artery. 
When  the  wound  is  small,  and  there  are  no  signs  of  injury  to  the 
thoracic  viscera,  it  is  not  always  possible  to  determine  whether  it 
has  penetrated  the  chest-wall ;  although  the  direction  and  situa- 
tion of  the  wound,  and  an  account  of  the  way  in  which  it  was 
inflicted,  may  point  to  its  having  done  so.  Under  these  circum- 
stances, the  wound  should  on  no  account  be  probed,  but  the 
patient  treated  as  if  the  wound  had  penetrated,  and  watched  for 
signs  of  inflammatory  complications.  The  symptoms  and  treat- 
ment will  depend  upon  the  viscus  wounded.  (See  IVonnds  of 
Thoracic  Viscera.') 

Injuries  of  the  Contents  of  the  Chcsi. 

These  may  be  divided  into  injuries  of  the — i,  pleura  and  lung  ; 
2,  pericardium  and  heart  ;  and  3,  large  blood-vessels. 

I.  Injuries  of  the  pleura  and  lung. —  Contusion  of  the  lung 
without  an  external  wound  may  be  produced  by  a  severe  crush  of 
or  blow  upon  the  chest.  The  visceral  layer  of  the  i)leura  mayor 
may  not  be  lacerated.  It  is  attended  with  paroxysmal  dyspnrea, 
cough,  localized  dulness,  and  crepitation,  followed  in  a  few  days 
by  expectoration  of  rusty  sputa.  If  the  visceral  layer  of  the 
pleura  is  lacerated,  blood  and  air  may  escape  into  the  pleural 
cavity,  and  there  will  then  be  in  addition  to  the  above,  signs  of 
h?emo- pneumothorax.  The  patient  usually  recovers  in  a  few 
days,  but  pneumonia,  pleurisy,  or  abscess  or  gangrene  of  the  lung 
may  occasionally  ensue. 

Wounds  of  the  pleura  and  lung  may  be  produced  by  the  frag- 
ments of  a  broken  rib,  or  by  a  stab  or  gunshot.  When  attended 
with  a  ]jenetrating  wound  of  the  chest,  they  are  very  serious. 
The  pleura  alone  may  be  wounded,  but  more  often  the  lung  is  in- 
jured at  the  same  time.  Signs. — No  single  symptom  is  sufificient 
to  make  it  certain  that  the  lung  has  been  wounded  ;  but  where 
several  of  the  following  are  present,  the  diagnosis  becomes  fairly 
certain.  Thus,  there  may  be  severe  shock,  abdominal  breathing, 
and  cough  with  expectoration  of  frothy  blood-stained  mucus,  or 
even  of  pure  blood.     If  there  is  an  external  wound,  there  will  be 


INJURIES    OF    THE    HEART   AND    PERICARDIUM.  37I 

escape  of  air  intimately  mixed  with  blood,  and  accompanied  by  a 
peculiar  hissing  noise  {hcemaiopncea)  ;  or  if  there  is  no  external 
wound,  emphysema  in  the  region  of  the  fractured  rib.  When  the 
pleura  alone  is  injured,  a  very  rare  accident,  the  signs  are  similar  ; 
but  no  blood  is  coughed  up,  and  though  air  may  escape  from  the 
external  wound  if  there  be  one,  it  is  not  churned  into  a  fine  froth 
with  the  blood,  as  it  does  not  come  from  the  lung,  but  is  simply 
drawn  in  and  out  of  the  pleura  through  the  wound  in  the  parietes 
during  inspiration  and  expiration.  Complications. — Hjemothorax, 
pneumothorax,  emphysema,  hsemorrhage,  and  later  pleurisy  and 
pneumonia  (see  Complications  of  Injuries  of  Chest).  Treatment. 
— Absolute  rest,  ice  to  suck,  opium  to  subdue  pain,  closure  of  the 
wound  if  small,  or  insertion  of  drain-tube  if  large,  and  antiseptic 
dressings,  with  such  treatment  as  is  appropriate  for  the  complica- 
tions that  maybe  present  (see  below).  If  the  pleura  alone  is 
injured,  the  external  wound  should  be  closed,  unless  any  compli- 
cation exists,  and  dressed  antiseptically. 

2.  Injuries  of  the  heart  and  pericardium. —  Contusions, 
wounds,  and  rupture  of  the  pericardium  may  at  times  be.produced 
by  a  severe  crush  of  the  chest-walls  ;  but  are  more  often  due  to 
the  penetration  of  a  fragment  of  a  broken  rib,  or  to  a  stab  or  gun- 
shot. In  the  last  two  instances  the  heart  is  generally  also  in- 
volved. Signs. — Severe  shock,  hsemorrhage,  the  position  and 
direction  of  the  wound,  and  subsequently  symptoms  of  pericarditis. 
The  prognosis  is  always  very  serious,  death  occurring  either  from 
the  effused  blood  impeding  the  heart's  action,  or  from  pericarditis. 
The  treatment  consists  in  absolute  rest,  the  local  application  of 
cold,  and  if  inflammation  threatens,  of  leeches.  Should  the 
heart's  action  become  seriously  impeded  by  effused  blood,  serum, 
or  pus,  aspiration  or  free  incision  and  drainage  may  be  required. 
When  there  is  an  external  wound  it  should  be  dressed  anti- 
septically. 

Wounds  of  the  heart,  especially  when  they  penetrate  one  of  its 
cavities  and  particularly  an  auricle,  are  generally  instantaneously 
fatal  from  shock  or  haemorrhage.  Remarkable  exceptions,  how- 
ever, occur,  and  patients  have  been  known  to  linger  for  a  few 
hours  or  a  few  days,  or  even  to  recover.  Signs. — When  not  at 
once  fatal,  a  wound  of  the  heart  is  attended  with  great  collapse, 
syncope,  a  fluttering  pulse,  and  dyspnoea,  and  later  with  symp- 
toms of  pericarditis.  The  treatment  is  the  same  as  that  for  a 
wound  of  the  pericardium. 

Ruptuj'e  of  the  heart,  though  rare,  occasionally  occurs  as  the 
result  of  great  external  violence  to  the  chest-walls,  or  of  some 
sudden  exertion  on  the  part  of  a  patient  suffering  from  disease  of 
the  heart's  substance.     Death  is,  as  a  rule,  almost  instantaneous. 


372 


INJURIES   OF   REGIONS. 


3.  WorNTS  OF  THE  LARGE  BLOOD  VESSELS,  as  the  aorta  or  vena 
cava,  are  almost  invariably  and  immediately  fatal,  and  require  no 
further  comment  here. 


Fig.  126. 


CompUcatious  of  Injuries  of  the  Chest. 

The  chief  complications  attending  injuries  of  the  chest  are  : — 
I,  external  haemorrhage;  2,  hemothorax;  3,  pneumothorax ;  4, 
emphysema  ;  5,  prolapse  and  hernia  of  the  lung  ;  6,  pleurisy  ;  7, 
pneumonia;  8,  haemopericardium ;  9,  pericarditis;  10,  medias- 
tinal abscess. 

I.  External  haemorrhage  in  penetrating  wounds  of  the  chest- 
walls  may  come  from  : — (i),  an  intercostal  artery  ;  (2),  the  in- 
ternal mammary  artery;  (3),  a  wound  of  the  lung;  or  (4),  a 
wound  of  the  heart  or  one  of  the  large  vessels.  Haemorrhage 
from  an  intercostal  or  the  internal  mam- 
mary artery,  though  it  may  generally  be 
known  by  the  blood  escaping  in  jets,  is 
sometimes  difficult  to  distinguish  from 
hjeaiorrhage  from  the  lung.  In  such  a 
case  it  is  said  that  if  a  card  be  introduced 
into  the  wound,  the  blood,  if  it  comes 
from  an  artery  in  the  chest-wall,  will  flow 
over  the  outer  surface  of  the  card,  but  if 
it  comes  from  the  lung  will  well  up  around 
the  card.  Hemorrhage  from  the  heart 
or  one  of  the  large  vessels  is,  as  a  rule, 
immediately  fatal.  Treatment. — i.  An 
intercostal  artery  should,  if  possible,  be 
tied  ;  otherwise  pressure  forceps  may  be 
left  on,  or  the  artery  with  the  periosteum 
may  be  separated  from  the  lower  half  of 
the  rib  and  then  tied,  or  a  portion  of  the  rib  may  be  excised. 
Where  assistance  is  not  at  hand,  the  centre  of  a  sheet  of  lint 
(wrung  out  of  an  antiseptic  solution)  may  be  pushed  into  the 
pleural  cavity  and  the  hollow  stuffed  firmly  with  antiseptic  wool. 
On  drawing  on  the  lint  the  artery  will  be  compressed  against  the 
interior  of  the  chest-wall  as  shown  in  the  accompanying  diagram. 
(Fig.  126.)  2.  The  internal  mammary  in  the  four  u|)per  spaces 
can  be  easily  tied  ;  in  the  lower  spaces  a  jiortion  of  the  costal 
cartilage  must  be  first  cut  away.  3.  When  the  bleeding  is  from 
the  lung  the  ])atient  must  be  ])laced  at  perfect  rest  on  the  injured 
side,  and  an  ice-bag  applied.  Internally,  lead  and  oi)inm,  gallic 
acid,  or  ergot,  may  be  given.  Some  recommend  the  closing  of 
the  external  wound  and  the  application  of  a  bandage  to  the  chest, 


Method  of  compressing  a 
wounded  intercostal  artery. 
A.  Artery,  i,.  Sheet  of  lint. 
K.  R.  Ribs.  \v.  PliiR  of  anti- 
septic wool. 


EMPHYSEMA.  373 

SO  that  the  blood  may  collect  in  the  pleura,  press  on  the  lung,  and 
thus  stop  the  bleeding. 

2.  HiEMOTHORAX.  Or  hcemorrhage  into  the  pleura,  may  occur 
either  with  or  without  an  internal  wound.  It  is,  perhaps,  most 
often  due  to  a  fragment  of  a  broken  rib  penetrating  the  lung  or 
wounding  an  intercostal  artery.  The  signs  are  those  of  internal 
haemorrhage  with  rapidly  extending  dulness  to  percussion,  absence 
of  breathing  sounds,  bulging  of  the  intercostal  spaces,  and  in- 
creasing dyspnoea.  It  may  be  distinguished  from  pleurisy  and 
pneumonia  by  coming  on  immediately  after  the  injury,  and  by  the 
absence  of  fever.  Treatment. — Similar  to  that  for  hgemorrhage 
from  a  wounded  lung.  Should  the  breathing  become  dangerously 
embarrassed,  the  blood  must  be  drawn  ofT  with  the  aspirator. 
Should  suppuration  occur,  the  chest  must  be  opened  and  freely 
drained. 

3.  Pneumothorax,  or  air  in  the  pleura,  is  generally  the  result 
of  a  wound  of  the  lung  by  a  fragment  of  a  broken  rib.  It  may 
be  known  by  tympanitic  resonance,  absence  of  breathing  sounds, 
or  amphoric  breathing,  metallic  tinkling,  bulging  of  the  intercostal 
spaces,  and  increasing  dyspnoea.  When  combined  with  haemo- 
thorax  or  with  pleuritic  effusion,  the  lower  part  of  the  chest  will 
be  dull  to  percussion,  and  a  splashing  sound  on  shaking  the  patient 
{siucussion)  may  be  heard  on  auscultation.  The  air  is  usually 
absorbed,  but  should  the  breathing  become  seriously  affected  it 
may  be  removed  with  the  aspirator  or  allowed  to  escape  through 
a  cannula  left  in  the  chest  and  protected  by  an  antiseptic  wool 
•dressing. 

4.  Emphysema,  or  air  in  the  connective-tissue  spaces,  is  some- 
times called  surgical  emphysema  to  distinguish  it  from  the  medical 
affection  of  the  same  name  in  which  the  air-cells  of  the  lung  are 
dilated.  It  is  generally  due  to  a  wound  of  the  lung  combined 
with  a  laceration  of  the  parietal  and  visceral  layers  of  the  pleura, 
and  is  a  very  frequent  complication  of  fractured  ribs.  The  air 
either  escapes  into  the  pleura  at  each  inspiration,  and  thence  dur- 
ing expiration  is  forced  through  the  parietal  layer  into  the  subcu- 
taneous connective  tissue,  or  it  passes,  if  there  are  adhesions  be- 
tween the  two  layers  of  the  pleura,  directly  from  the  lung  into  the 
subcutaneous  tissue.  More  rarely  it  is  due  to  a  rupture  of  the 
lung  without  injury  of  the  pleura,  the  air  then  escaping  at  the  root 
of  the  lung  into  the  posterior  mediastinum,  and  thence  into  the 
connective  tissue  of  the  neck  and  arms.  More  rarely  still  it  may 
occur  without  a  wound  of  the  lung,  or  even  without  a  wound  of 
the  pleura.  Signs. — The  emphysema,  though  usually  limited  to 
the  seat  of  injury,  may  extend  somewhat  widely  around  it,  and  in 
rare  instances  has  spread  over  the  whole  body.     It  gives  rise  to  an 


374  INJURIES   OF   REGIONS. 

ill-defined  flattened  swelling,  unattended  with  signs  of  inflamma- 
tion and  unaltered  on  inspiration  and  expiration.  On  pressing  on 
the  swelling  a  peculiar  crackling  sensation  is  experienced,  like 
that  of  rubbing  the  hair  between  the  fingers.  Treaf/neiit. — A  pad 
and  bandage  is  all  that  is  usually  necessary,  but  should  the  air 
instead  of  becoming  absorbed  extend  so  widely  as  to  interfere 
with  respiration,  a  puncture  or  two  must  be  made  to  let  it  escape. 

5.  Prolapse  and  hernia  of  the  lung. — Prolapse  of  the  lung 
occasionally  occurs  through  a  wound  in  the  chest-wall.  It  should 
be  returned  by  gentle  pressure,  the  wound  being  slightly  enlarged 
if  necessary.  If  the  prolapsed  portion  has  become  adherent  and 
congested  it  may  be  removed  by  the  knife  or  ligature,  taking  care 
not  to  break  down  the  adhesions  of  the  visceral  layer  of  the  pleura 
to  the  chest-wall  and  so  open  the  pleural  cavity.  Hernia  of  the 
lung  is  sometimes  met  with  after  a  penetrating  wound  of  the  chest 
has  cicatrized,  or  even  when  there  has  been  no  wound  of  the  skin. 
It  forms  a  soft,  cre])itating,  resonant  swelling,  which  can  be  made 
smaller  by  pressure,  and  generally  becomes  more  prominent  on 
forced  expiration  or  coughing.  On  listening  over  it  a  harsh  vesi- 
cular murmur  is  heard.  The  treatment  consists  in  protecting  it 
with  a  properly-shaped  pad  or  leather  shield  moulded  to  the  part. 

For  an  account  of  such  complications  as  Pleurisy,  Pneumonia, 
Hamopericardium,  Pericarditis,  and  Mediastinal  Abscess,  a  work 
on  Medicine  must  be  consulted. 

Operations  on  the  chest. — Tapping  the  pleura  should  be  done 
when  the  efllision  is  serous  without  admitting  air,  either  with  the 
aspirator  or  with  the  syphon-trocar  and  cannula.  The  spot  usually 
selected  is  the  sixth  intercostal  space  in  the  mid-axillary  line.  A 
small  incision  is  sometimes  first  made  through  the  skin,  which 
should  be  drawn  down  on  the  rib  so  that  the  wound  may  be  valvu- 
lar, but  such  an  incision  is  quite  unnecessary.  The  needle  of  the 
aspirator  or  the  trocar  and  cannula  is  then  thrust  into  the  pleural 
cavity.  The  fluid  should  be  allowed  to  escape  slowly,  and  its  flow 
stopped  for  a  minute  or  so  if  coughing  occurs.  The  instrument 
must  be  withdrawn  should  any  blood  become  mixed  with  the  fluid. 
The  wound  should  be  closed  with  a  pad  of  antiseptic  gauze. 

Incision  and  drainage  0/  the  pleura  may  be  required  for  empy- 
ema, the  removal  of  putrid  clots,  etc.  The  incision  may  be  made 
in  the  sixth  intercostal  space  in  the  mid-axillary  line,  or  in  the 
ninth  or  tenth  space  in  a  line  with  the  angle  of  the  scapula.  Be- 
fore operating  it  is  a  good  rule  to  make  sure  of  the  presence  of 
pus  by  ptmcture  with  an  exploring  syringe,  and  make  the  incision 
at  the  spot  where  it  is  found.  An  anaesthetic  should  be  given, 
and  a  careful  dissection  made  between  the  ribs  down  to  the 
pleura,  or  a  director  may  be  thrust  through  the  muscles  into  the 


OPERATIONS   ON   THE   CHEST.  375 

pleural  cavity  and  the  wound  sufficiently  enlarged  by  passing  a 
dressing  forceps  along  the  director  and  forcibly  opening  the 
blades.  A  drainage-tube  should  then  be  inserted.  The  pleura 
had  better  not  be  washed  out,  since  during  this  procedure  sudden 
death  may  occur.  Even  when  foul,  the  pus  will  usually  become 
sweet  in  a  few  days  after  free  drainage  has  been  established.  If 
the  space  between  the  ribs  is  insufficient  a  piece  of  a  rib  may  be 
excised.  The  wound  should  be  treated  antiseptically,  and  if  pus 
again  collects  a  counter-opening  may  be  made,  but  this  is  seldom 
advisable  or  necessary. 

Thoracoplasty  or  Estla?ider''s  opei-ation  consists  in  removing  a 
portion  of  several  of  the  ribs,  for  the  purpose  of  allowing  the 
chest-walls  to  fall  in,  in  cases  of  empyema  where,  after  the  pleura 
has  been  drained,  the  lung  in  consequence  of  adhesions  does  not 
expand.  An  incision  three  or  four  inches  in  length  may  be  made 
obliquely  downwards  and  inwards  over  the  side  of  the  chest,  just 
in  front  of  the  latissimus  dorsi,  across  the  ribs  the  portions  of 
which  it  is  intended  to  excise.  The  edges  of  the  wound  being 
retracted  to  expose  the  ribs,  an  incision  is  next  made  through  the 
periosteum  along  the  course  of  each  rib  for  the  required  distance, 
the  periosteum  separated  with  a  raspatory  from  both  the  outer 
and  inner  surface,  and  the  rib  then  cut  through  with  the  saw  or 
bone-forceps  at  each  end  of  the  incision,  the  soft  parts  being 
protected  by  a  spatula  passed  beneath  the  rib. 

Pneumotomy,  or  incising  the  lung  for  the  purpose  of  opening 
an  abscess  or  hydatid  cyst,  or  of  draining  a  phthisical  or  bron- 
chiectatic  cavity,  has  in  a  few  instances  been  done.  An  incision 
is  made  down  to  the  pleura,  a  portion  of  rib  being  excised ;  the 
lung  is  then  sewn  to  the  pleura,  before  the  latter  is  opened,  by 
stitches  passed  deeply  into  the  lung  by  means  of  Hagedorn's 
needles.  A  trocar  and  cannula  connected  with  an  aspirator  are 
next  thrust  into  the  cavity  in  the  lung,  pressure  being  kept  up  the 
while  to  prevent  infection  of  the  pleura  ;  or  the  wound  made  by 
the  cannula  may  be  cautiously  enlarged  by  dressing  forceps. 

Pneumonectomy,  or  excision  of  a  portion  of  the  lung  for  localized 
tubercle,  has  been  successfully  accomplished  in  a  few  cases.  The 
pleura  having  been  lilled  with  aseptic  air  to  cause  collapse  of  the 
lung,  is  opened,  the  collapsed  lung  transfixed  below  the  disease 
with  a  blunt  needle  armed  with  aseptic  silk,  the  silk  tied,  and  the 
lung  cut  away  above  the  ligatures. 

Tapping  the  pericardium. — The  puncture  should  be  made  with 
the  aspirator  in  the  fourth  or  fifth  intercostal  space  on  the  left  side, 
about  two  inches  from  the  sternum  or  immediately  to  the  left  of 
the  sternum.  Care  should  be  taken  not  to  injure  the  internal 
mammary  or  an  intercostal  artery,  and  not  to  thrust  the  needle 
too  deep  lest  the  heart  be  punctured. 


'37^  INJURIES   OF    REGIONS. 

Incision  and  drainage  of  the  pericardium  may  be  required  for 
pus  in  its  cavity.  An  incision  about  two  inches  long  should  be 
made  along  the  upper  border  of  the  fifth  or  sixth  rib,  beginning 
one  inch  from  the  sternum.  When  the  pericardium  is  reached  it 
should  be  freely  opened,  a  drainage-tube  inserted,  and  antiseptic 
dressings  applied. 

INJURIES    OF    THE    ABDOMEN. 

Contusions  of  the  abdominal  wall,  especially  when  due  to  a 
sharp  or  sudden  blow  or  a  severe  crush,  should  always  be  re- 
garded as  serious,  as  they  may  be  complicated  by  grave  internal 
injuries.  Thus,  the  peritoneum  may  be  lacerated,  one  of  the 
viscera  ruptured,  or  a  large  blood-vessel  injured  and  blood  ex- 
travasated  into  the  peritoneum  or  subperitoneal  tissue  \  whilst 
among  the  minor  complications  may  be  mentioned  rupture  of  the 
rectus  or  other  muscle  of  the  abdominal  wall  accompanied  by 
blood  effusion  {hcematoma)  and  possibly  followed  by  suppuration 
and  abscess.  Even  where  no  injury  to  a  viscus  has  been  sus- 
tained, a  contusion  of  the  abdomen  is  nearly  always  attended 
with  shock  which  may  be  severe,  and  in  some  instances  has  been 
fatal,  probably  from  injury  to  the  solar  plexus.  The  sig7is  of  a 
simple  contusion  are  pain,  ecchymosis,  tenderness  and  swelling, 
with  a  varying  amount  of  shock.  A  ruptured  rectus  will  be  in- 
dicated by  pain  on  putting  the  muscle  into  action,  and  the 
presence  of  a  gap,  and  later  of  a  swelling  from  the  effusion  of 
blood.  A  blood-tumor  will  be  known  by  its  sudden  occurrence, 
and  absence  of  signs  of  inflammation.  Treatment. — The  patient 
should  be  treated  as  if  he  had  sustained  a  grave  injury,  since  it  is 
impossible  at  first  to  say  that  such  is  not  the  case.  Thus,  he 
should  be  placed  at  absolute  rest  in  bed,  hot  fomentations  applied 
to  the  abdomen  and  hot  bottles  to  the  extremities,  and  opium 
given  internally  ;  whilst  for  precaution's  sake  for  the  first  twelve 
or  twenty-four  hours  nothing  should  be  given  by  the  mouth,  or 
only  small  quantities  of  iced  milk.  Where  there  is  rupture  of  the 
rectus  the  jjarts  should  be  approximated  as  much  as  possible  by 
position.  If  a  blood-tumor  forms  cold  should  be  applied,  but  it 
should  on  no  account  be  opened,  as  the  blood  will  nearly  always 
in  time  be  absorbed. 

Laceraiion  of  the  I'ERI'joneum  may  occur  from  a  blow  or 
crush  of  the  abdomen  without  injury  of  the  viscera,  and  may  be 
complicated  when  a  large  vessel  has  been  ruptured  by  extravasa- 
tion of  blood  into  the  peritoneal  cavity  or  sub-peritoneal  tissue. 
There  are  no  special  signs  of  this  injury  ;  but  restlessness,  a  sensa- 
tion of  sinking,  yawning,  an  anxious  countenance,  coldness  and 
blanching  of  the  surface  when  complicated  by  hemorrhage,  with 


RUPTURE    OF    THE    VISCERA.  377 

an  absence  of  vomiting  and  often  of  pain,  are  said  to  indicate  it. 
Peritonitis  nearly  always  quickly  supervenes.  Treatvient. — Like 
that  of  peritonitis. 

Suppuration  and  abscess  may  follow  on  any  injury  of  the 
abdominal  walls,  or  extravasation  of  urine  ;  or  may  be  due  to  the 
breaking  down  of  a  blood-tumor  or  syphilitic  gumma,  or  to 
disease  of  the  bones  forming  the  walls  of  the  abdomen  or  pelvis. 
The  suppuration  may  be  acute  or  chronic,  superficial  or  deep. 
When  deep  it  is  very  apt  to  be  diffuse,  and  extend  along  the  mus- 
cular planes  or  between  the  peritoneum  and  transversalis.  When 
superficial,  except  as  the  result  of  extravasation  of  urine,  it  is 
generally  circumscribed  and  often  confined  to  the  sheath  of  the 
rectus.  Signs. — The  acute  form  is  attended  with  the  general  and 
local  symptoms  of  inflammation,  followed  by  those  of  suppura- 
tion, and  subsequently  by  the  signs  of  an  abscess.  In  the 
chronic  form  there  will  probably  be  no  constitutional  signs ;  but 
a  localized  swelling,  either  superficial  or  deep,  will  generally  be 
present  in  which  fluctuation  may  be  detected.  Treatment. — 
Early  and  free  evacuation  of  the  pus. 

Rupture  of  the  viscera. — The  rupture  of  an  abdominal  viscus 
is  always  a  most  serious  accident,  and  one  which  is  frequently, 
though  not  invariably,  fatal.  Cause. — Generally  a  severe  crush 
of  the  abdomen,  as  between  the  bufters  of  railway  cars  ;  or  a  kick 
or  blow,  or  the  passage  of  a  wheel  over  the  abdomen.  Pathology. 
— Any  of  the  viscera,  except  perhaps  the  pancreas,  may  be  rup- 
tured ;  but  the  liver,  intestines,  kidneys,  and  bladder  are  those 
most  frequently  injured.  In  rupture  of  the  liver  and  spleen 
severe  hgemorrhage  Into  the  peritoneal  cavity,  followed  by  peri- 
tonitis, ensues,  unless  the  peritoneal  covering  escapes  rupture, 
when  no  blood  is  extravasated.  In  rupture  of  the  stomach,  gall- 
bladder, and  intestines  their  contents  escape  into  the  peritoneal 
cavity,  setting  up  rapidly-fatal  peritonitis,  though  in  the  case  of 
the  stomach  and  gall-bladder  the  more  immediate  danger  is 
death  from  shock.  Rupture  of  the  intestine  usually  occurs  where 
the  duodenum  joins  the  jejunum.  The  large  intestine  is  rarely 
injured,  in  consequence  of  its  protected  position.  Rupture  of  the 
kidney  is  a  less  faral  accident,  as  the  organ  lies  well  behind  the 
peritoneum  ;  but  when  the  crush  is  severe  it  may  be  attended 
with  haemorrhage  or  peritonitis.  It  is  liable  to  be  followed  by 
perinephritic  abscess.  For  rupture  of  the  bladder,  see  Injuries 
of  Pelvis. 

The  signs  of  a  ruptured  viscus  are  often  obscure,  but  great 

shock,  extreme  collapse,  and  intense  localized  pain,  together  with 

the  history  of  a  severe  crush  of  the  abdomen,  point  to  such  an 

injury  having  occurred.     Beyond  a  surmise  that  one  of  the  viscera 

i6* 


378  INJURIES   OF   REGIONS. 

has  been  injured,  it  may  be  quite  impossible  to  localize  the  mis- 
chief. The  following  signs,  however,  may  serve  to  indicate  the 
probable  nature  of  the  legion  :  thus — i.  In  rupture  of  the  liver 
there  may  be  pain  in  the  right  hypochondrium,  perhaps  a  fracture 
of  the  ribs  over  the  liver,  byraptoms  of  internal  haemorrhage,  in- 
crease of  the  hepitic  dulness  in  consequence  of  blood  extravasa- 
tion, and  later  peritonitis,  jaundice,  and  very  occasionally  diabetes. 
When  the  rupture  is  slight,  or  the  peritoneal  covering  is  not  torn, 
the  injury  may  remain  unsuspected  and  the  patient  recover.  Or 
after  a  few  days  the  peritoneal  covering  may  give  way  and  peri- 
tonitis ensue.  2.  In  ruptuie  of  the  spleen  the  signs  are  similar, 
save  that  the  pain  is  referred  to  the  left  side,  and  there  may  be 
increase  of  the  splenic  dulness,  and  perhaps  fracture  of  the  ribs 
in  that  region.  3.  Rupture  of  the  stomach  is  attended  with  ex- 
treme collapse,  and  if  not  rapidly  fatal,  with  intense  pain  in  the 
region  of  the  stomach,  free  gas  in  the  peritoneal  cavity  and  hence 
loss  of  liver  dulness,  and  vomiting  of  blood,  followed  by  peri- 
tonitis. 4.  In  rupture  of  the  o;all-bladder  there  is  pain  in  the 
region  of  the  liver,  followed  by  localized  or  general  peritonitis, 
and  if  the  patient  survive,  by  distension  with  fluid  of  the  peritoneal 
cavity  and  great  emaciation;  on  puncture,  a  bile-stained  fluid  is 
withdrawn.  5.  In  rupture  of  the  intestines,  in  addition  to  the 
collapse  and  intense  pain  radiating  over  the  abdomen,  there  may 
be  vomiting,  first  of  the  contents  of  the  stomach,  then  of  bile,  and 
then  of  altered  blood  ;  blood  in  the  stools;  tympanites  with  dul- 
ness in  the  flanks ;  and,  later,  peritonitis.  6.  AVhen  a  kidney  is 
ruptured  there  will  probably  be  a  history  of  a  blow  or  other 
injury  of  the  loin,  increased  frequency  of  micturition,  blood- 
stained urine,  urinary  extravasation  in  the  loin,  pain  and  signs  of 
bruising  in  the  lumbar  region,  retraction  of  the  testicle,  and,  later, 
pus  in  the  urine,  and  signs  of  deep-seated  suppuration  {peri- 
nephritic  abscess)  or  peritonitis.  7.  Rupture  of  the  ureter  may 
give  rise  to  a  fluctuating  retroperitoneal  swelling  containing  urine. 
Treatment. — In  rupture  of  the  liver,  spleen,  or  kidney,  ice  may 
be  applied  over  the  jxart,  and  gallic  acid  or  ergot  given  internally 
to  restrain  the  haemorrhage.  Stimu.lants  must  be  avoided,  but 
fluid  nourishment  should  be  given  in  very  small  quantities  at  a 
time  or  by  the  rectum.  In  rujnure  of  the  spleen  the  removal  of 
the  organ  is  probably  the  be.->t  way  of  preventing  death  from 
haemorrhage.  In  rupture  of  the  stomach  or  intestines,  the  abdo- 
men should  be  opened,  the  rent  sewn  up  by  a  Lembert's  suture, 
and  the  peritoneal  cavity  thoroughly  cleansed  by  irrigation  with  a 
weak  boracic  solution.  Subsequently  the  patient  should  be  kept 
under  the  influence  of  opium  if  there  is  much  ])ain,  and  nothing 
whatever  be  given  by  the  mouth  for  the  first  twelve  to  twenty-four 


SIMPLE    PENETRATING    WOUNDS    OF    THE    VISCERA.  379 

hours.  Nutrient  enemata  and  stimulants,  if  the  strength  flags, 
should  be  administered.  In  rupture  of  the  kidney  an  incision 
in  the  loin  or  nephrectomy  may  become  necessary.  The  swelling 
following  rupture  of  the  ureter  may  require  tapping  or  free 
drainage. 

Wounds  of  the  abdomen  may  be  divided  into  the  penetrating 
and  non-penetrating,  according  as  they  do  or  do  not  involve  the 
peritonea]  cavity. 

Non-penetrating  wounds  should  be  treated  like  wounds  in 
other  situations,  especial  care,  however,  being  taken  to  establish  a 
good  drain,  as  should  they  extend  deeply  they  are  apt  to  be  com- 
plicated by  eiTusion  of  blood  or  suppuration  in  the  sub-peritoneal 
tissue.     They  are  liable  to  be  followed  by  ventral  hernia. 

Penetrating  wounds  are  such  as  involve  the  peritoneal  cavity. 
They  may  be  divided  into  the  following  : — i.  Simple  penetrating 
wounds  without  injury  or  protrusion  of  the  viscera.  2.  Penetrat- 
ing wounds  without  injury,  but  without  protrusion  of  the  viscera. 
3.  Penetrating  wounds  with  protrusion,  but  without  injury  of  the 
viscera.  4.  Penetrating  wounds  with  both  protrusion  and  injury 
of  the  viscera, 

I.  Simple  penetrating  wounds  without  injury  or  protrusion 
of  the  viscera. — When  the  wound  is  large,  there  will  usually  be 
no  difficulty  in  ascertaining  the  fact  that  the  viscera  have  escaped 
injury.  If,  however,  the  wound  is  very  small — a  mere  puncture, 
or  made  obhquely,  it  may  be  difficult  or  impossible  to  say 
whether  any  injury  to  the  viscera  has  been  done,  or,  indeed, 
whether  the  abdominal  cavity  has  been  penetrated.  In  such  a 
case  it  has  hitherto  been  taught  that  the  wound  should  on  no  ac- 
count be  probed  for  the  purpose  of  settling  the  point,  but  the 
patient  treated  as  if  the  wound  had  penetrated,  and  had  not  in- 
jured the  viscera.  If  all  antiseptic  precautions  are  taken,  how- 
ever, it  is  questionable  whether  the  safer  course  is  not  to  thor- 
oughly explore  the  wound,  not  only  by  probing,  but  by  enlarging 
it  if  necessary,  so  as  at  once  to  ascertain  whether  it  has  penetrated 
the  peritoneum,  and  whether  the  viscera  have  escaped  injury,  and 
not  to  wait  till  the  diagnosis  is  settled  by  the  onset  of  peritonitis. 
Where  there  are  signs  of  internal  hcemorrhage  no  surgeon 
would,  I  presume,  hesitate  to  search  for  the  bleeding  vessel. 
Treatment. — Large  wounds  should  be  thoroughly  cleansed  with 
w-eak  boracic  acid  lotion  (2  per  cent.),  and  united  with  fishing- 
gut  or  silk  sutures,  which  should  be  passed  through  the  peritoneum 
as  well  as  the  edges  of  the  wound,  so  as  to  bring  the  two  free 
surfaces  of  the  serous  membrane  into  contact.  If  this  is  not  done, 
the  discharge  from  the  deep  part  of  the  wound  may  make  its  way 
into  the  peritoneal  cavity  and  set  up  peritonitis.     In  the  case  of 


380  INJURIES    OF    REGIONS. 

punctured  wounds,  it  has  usually  been  the  custom  to  merely  close 
them  and  apply  some  antiseptic  dressing.  As  a  rule,  however,  it 
will  probably  be  safer  to  enlarge  them,  and  having  ascertained 
that  the  viscera  have  escaped,  to  treat  them  as  described  above. 
In  any  case  the  patient  should  be  placed  at  absolute  rest  in  bed 
and  fed  by  the  rectum  or  by  small  quantities  of  iced  milk  for  the 
first  few  days.  Many  surgeons  would  give  opium  in  small  doses, 
but  it  is  not  necessary  unless  there  is  pain.  Should  peritonitis 
supers'ene,  it  must  be  treated  as  described  under  that  head. 

II.  Penetrating  wounds  with  injury,  but  without  protrusion 
OF  THE  VISCERA. — When  the  wound  is  large,  and  the  injured  viscus 
can  be  seen,  the  nature  of  the  injury  will  probably  be  obvious. 
When,  however,  the  wound  is  small,  unless  there  be  an  escape  ex- 
ternally of  fseces,  gas,  bile,  urine,  or  the  contents  of  the  stomach, 
there  are  no  primary  signs,  with  the  exception  perhaps  of  emphy- 
sema about  the  wound,  absolutely  diagnostic  of  a  viscus  having 
been  injured.  Intense  pain,  and  extreme  collapse,  if  present,  no 
doubt  point  to  such  an  injury  having  probably  occurred ;  but 
both  pain  and  shock  are  so  variable  as  really  to  afford  little 
guidance.  Later  the  presence  of  free  gas  in  the  peritoneal 
cavity  and  the  escape  of  blood  from  the  anus  make  it  highly 
probable  the  intestine  has  been  wounded.  In  a  doubtful  case  of 
wound  of  the  intestine  the  rectum  may  be  inflated  with  hydrogen 
by  Senn's  rubber  balloon.  If  a  gut  is  wounded  the  gas  will  escape 
through  the  rent  into  the  peritoneum  and  thence  through  the  ex- 
ternal wound,  where  it  will  ignite  on  applying  a  light,  thus  settling 
the  diagnosis.  In  a  doubtful  wound  of  the  stomach  this  viscus 
may  be  inflated  by  a  tube  passed  through  the  mouth.  The 
tympanites  will  be  confined  to  the  stomach  if  the  viscus  is  sound, 
or  spread  to  the  rest  of  the  abdomen  and  eftace  the  liver  dulness 
if  it  is  injured.  Any  of  the  viscera  may  be  implicated  ;  but 
wounds  of  the  liver,  gall-bladder,  spleen,  and  stomach,  are  much 
less  common  than  wounds  of  the  intestine.  The  danger  to  be 
apprehended  is  haemorrhage  in  the  case  of  the  liver  or  spleen, 
extravasation  in  the  case  of  a  hollow  viscus,  and  in  all,  peritonitis. 
The  amount  of  extravasation  will  depend  upon  the  size  of  the 
wound,  and  whether  the  viscus  was  distended  or  empty  at  the 
time  of  injury ;  when  the  wound  is  a  mere  puncture,  there  may  be 
none.  If  the  extravasation  is  but  slight,  or  escapes  externally 
through  the  wound  in  the  parietes,  it  may  be  cut  off  from  the 
general  peritoneal  cavity  by  a  local  peritonitis,  and  the  patient 
recover.  An  extensive  extravasation  is  always  followed  by  diffuse 
septic  peritonitis,  which,  unless  surgical  measures  are  undertaken, 
will  certainly  prove  fatal  in  a  few  days.  Treatment — i.  If  the 
wound   in   the   parietes  is  extensive,   the  injured  viscus,   if  the 


PENETRATING    WOUNDS    WITH    INJURY    OF    THE    VISCERA.         38 1 

stomach  or  hrtestine,  should  be  drawn  gently  through  the  aperture 
and  the  wound  of  its  coats  united  by  Lembert's  sutures.  Should 
the  intestine  be  torn  completely  across,  its  continuity  should  be 
restored  by  some  form  of  circular  enterorrhaphy,  as  Senn's, 
Maunsell's,  or  Paul's,  or  by  Senn's  bone-plates,  or  by  Murphy's 
button.  If  its  coats  are  much  lacerated,  the  lacerated  portions 
should  be  iirst  excised.  These  methods  have  so  reduced  the 
time  required  for  restoring  the  continuity  of  divided  intestine  that 
only  in  exceptional  cases  should  the  patient's  general  condition 
render  it  necessary  to  draw  the  injured  gut  into  the  wound,  stitch 
it  to  the  parietes,  and  make  an  artificial  anus.  In  gunshot 
wounds  of  the  intestines  Senn's  inflation  method  is  useful  in  de- 
termining if  there  be  one  or  more  wounds.  The  rectum  is  first 
inflated  and  the  lowest  wound  detected  by  the  escape  of  the  gas. 
This  wound  is  then  sutured,  the  inflation  repeated,  and  the  gas 
extends  up  to  the  next  wound,  and  so  on.  If  the  liver  is  wounded 
an  attempt  may  be  made  to  unite  the  peritoneal  surface  by 
sutures,  or  if  the  wound  is  deep  it  may  be  plugged  with  iodoform- 
gauze  and  the  wound  in  the  parietes  be  left  partially  open  for  the 
purposes  of  drainage  and  the  subsequent  removal  of  the  plugs. 
If  the  gall-hladder  is  penetrated  the  wound  should  be  sewn  up,  or 
the  edges  of  the  wound  if  lacerated  stitched  to  the  abdominal 
parietes,  or  the  gall-bladder  removed.  If  the  spleen  is  injured, 
extirpation  of  the  organ  appears  to  be  the  best  method  of  arrest- 
ing the  otherwise  fatal  haemorrhage.  After  the  wounded  viscus 
has  been  treated  in  one  or  other  of  the  ways  described  above,  the 
peritoneal  cavity  should  be  thoroughly  cleansed  from  all  blood 
and  other  extravasation  by  irrigation  with  warm  water  or  boric 
acid  solution  (2  per  cent.),  and  the  wound  in  the  parietes  closed 
as  after  a  simple  penetrating  wound  ;  or  if  it  remains  doubtful 
how  far  the  cleansing  has  been  successful,  a  Keith's  drain-tube 
should  be  inserted,  packed  round  with  iodoform  gauze,  and  the 
wound  in  the  parietes  left  partially  open.  2.  If  the  wound  in  the 
parietes  is  small,  the  safer  course  is  probably  to  enlarge  the 
wound,  and  treat  the  wounded  viscus  as  described  above.  The 
genej-al  treatment  consists  in  the  administration  of  opium  if  there 
is  much  pain ;  abstinence  from  all  nutriment  taken  by  the  mouth 
for  the  first  day  or  so,  and  subsequent  feeding  with  small  quan- 
tities of  iced  milk,  etc.,  and  the  employment  of  nutrient  enemata. 
Absolute  rest  is  imperative.  Should  peritonitis  supervene,  it 
must  be  treated  as  described  under  that  head. 

Method  of  uniting  wounded  intestine. — If  the  wound  is  small  (a 
mere  puncture)  it  has  usually  been  taught  that  no  suture  will  be 
required,  since  the  mucous  membrane  will  protrude,  block  up  the 
wound,  and  prevent  extravasation  until  the  woimd  has  healed  by 


382 


INJURIES    OF   REGIONS. 


inflammatory  exudation  from  the  peritoneal  surface.  Gross's  ex- 
periments on  dogs  show,  however,  that  the  protrusion  of  mucous 
membrane  is  not  always  sufficient  even  in  minute  wounds  to  pre- 
vent the  escape  of  faecal  matter.  It  would,  therefore,  appear  to 
be  the  better  practice  in  all  cases  to  sew  up  the  wound,  however 
small.  This  is  now  usually  done  by  interrupted  sutures,  the  two 
peritoneal  surfaces  being  placed  in  contact.  The  sutures  are  best 
applied  by  Lembert's  method,  as  shown  in  the  accompanying 
diagram  (Fig.  127),  in  which  it  is  seen  that  the  suture  passes 


Fig.  128. 


Fig.  127. 


/M 


\  \ 


Section  of  intestine  united  by 
Lembi:rt's  suture. 


'  "       '  •   r  ■    f 
1  '    '•  I 

Intestine  united  by  Lembert's  suture. 


through  the  peritoneal  and  muscular  coats  only,  avoiding  the 
mucous  membrane,  since  if  this  is  included  there  is  danger  of 
peritonitis  from  leakage  along  the  thread.  The  sutures,  which 
may  consist  of  fine  China  silk,  should  be  introduced  about  two 
lines  from  the  edge  of  the  wound  and  brought  out  at  the  margin 
of  the  serous  coat,  and  then  passed  in  the  same  manner  on  the 
opposite  side  (Fig.  128).  If,  however,  the  edges  are  lacerated 
the  sutures  should  be  introduced  further  from  the  wound,  and 
brought  out  a  good  line  from  the  margin,  so  as  not  to  include 
the  bruised  tissues.  Sufficient  sutures  should  be  passed  to  ensure 
the  parts  being  everywhere  in  apposition,  and  should  not  be  tied 
too  tightly,  lest  gangrene,  the  commonest  cause  of  non-union, 
ensue.  The  peritoneal  surfaces  thus  pUiced  in  contact  unite  by 
adhesive  inflammation.  The  sutures  either  remain  encysted,  or 
ulcerate  through  the  mucous  membrane,  and  drop  into  the  interior 
of  the  bowel.  It  is  not  safe  to  suture  the  wound — (i)  when  the 
wound  runs  longitudinally  along  the  mesenteric  aspect,  inasmuch 
as  gangrene  of  the  part  cut  off  from  its  vascular  supply  will  inevi- 
tably ensue ;  (2)  when  suturing  would  reduce  the  lumen  of  the 
gut  to  less  than  half  its  normal  size;  (3)  when  there  is  much 
bruising  of  the  gut ;  (4)  when  there  are  several  wounds  close  to- 
gether.    In  such  cases  the  injured  portion  of  the  intestine  should 


PENETRATING    WOUNDS    WITH    INJURY    OF   THE   VISCERA. 


383 


be  excised  and  the  two  ends  united  by  some  form  of  circular 
enterorrhaphy,  or  an  intestinal  anastomosis  may  be  formed. 

Circular  enterorrhapliy  is  the  union  of  the  ends  of  the  com- 
pletely-divided intestine  with  the  peritoneal  surfaces  in  contact 
by  a  row  of  sutures  around  the  circumference  of  the  bowel.  The 
Lembert  method  of  a  single  row  and  the  Czerny-Lembert  method 
of  a  double  row  have  in  recent  years  usually  been  employed. 
The  objection  to  these  methods  is  the  great  number  of  sutures 
required,  and  hence  the  length  of  time  consumed  in  the  operation 


Fi(     i2g 


Fig.  130. 


RS 


Senn's  method  of  circular  enterorrhaptiy.  R.  Rubber  rings,  s.  Continuou;.  suture.  M. 
Mesentery.  RS.  Retaining  suture.  The  margin  of  intestine,  i  in  Fig.  129,  is  shown  turned 
in  at  I.I  in  Fig.  130. 


— a  serious  drawback  in  abdominal  cases — and  the  danger  of  ex- 
travasation at  the  mesenteric  attachment.  Many,  therefore,  em- 
ploy Senn's  modification  of  Jobert's  suture,  or  Maunsell's,  or 
Paul's  method  of  suture.  Senn's  method. — Having  determined 
which  is  the  upper  end  of  the  intestine,  as  by  applying  to  the  sur- 
face of  the  peritoneal  coat  a  little  common  salt,  v/hich  causes 
ascending  peristalsis  (Ncthnagel's  test),  line  the  lower  end  of  the 
upper  portion  of  the  bowel  with  a  soft,  pliable  rubber  ring  half  an 
inch  wide,  made  by  stitching  together  the  ends  of  a  rubber  band 
by  two  catgut  sutures.  Fix  the  ring  by  sewing  its  lower  margin 
with  a  continuous  catgut  suture  to  the  cut  end  of  the  bowel ;  the 
ring  prevents  bulging  of  the  mucous  membrane  and  causes  the 
end  of  the  bowel  to  slightly  taper,  and  thus  aids  its  subsequent 


384 


IXTURIES   OF   REGIONS. 


invagination  (Fig.  129).  Pass  two  catgut  sutures  with  a  needle 
at  each  end  from  within  outwards  through  the  upper  margin  of 
the  ring  and  all  the  coats  of  the  bowel,  one  suture  near  the 
mesenteric,  one  near  the  convex  surface  of  the  bowel.  Pass  the 
other  end  of  the  sutures  through  the  peritoneal  and  muscular  coat 
of  the  distal  portion  of  the  bowel  about  a  third  of  an  inch  from 
its  cut  margin.  Whilst  an  assistant  draws  on  the  four  ends  of  the 
two  sutures,  turn  in  the  margin  of  the  upper  end  of  the  distal  por- 
tion of  the  gut  evenly  by  the  aid  of  a  director,  and  at  the  same 
time  invaginate  the  ring-lined  proximal  portion  of  the  intestine 
into  the  distal  portion  (Fig.  130)  to  the  extent  of  the  whole  width 
of  the  ring.  Tie  the  sutures  only  sufficiently  tightly  to  prevent 
disinvagination.  The  two  peritoneal  surfaces  are  thus  held  in 
close  contact  by  the  rubber  ring.  The  intestinal  contents,  says 
Senn,  pass  freely  through  the  lumen  of  the  ring  from  above  down- 
wards, and  escape  from  below  is  impossible,  as  the  free  end  of  the 
intussuscipiens  secures  accurate  valvular  closure.  The  catgut 
sutures  fixing  the  ring  are  absorbed,  and  the  ring,  reconverted 
into  a  band,  is  passed  per  anum.  The  invagination  sutures  are 
believed  by  Senn  to  be  removed  by  substitution  on  the  part  of  the 
tissues.  Hence  the  punctures  of  the  bowel  remained  closed  and 
extravasation  is  prevented.  MaunselPs  method. — Bring  the  two 
ends  of  the  divided  bowel  together  by  two  temporary  sutures 
passed  through  all  the  coats,  one  suture  at  the  mesenteric  attach- 

FiG.  131. 


iJU^i4^j't:s:^jWj5'itmjvilJ 


Maunsell's  method  of  circular  enterorrhaphy.  a  n  c.  rcritoneal,  muscular  and  mucous  cents. 
F.  Mesentery,  d  d.  Temporary  sutures  uniting  proximal  and  distal  portions  ol  divided 
intestine,  and  passed  out  througli  longitudinal  slit  made  in  the  proximal  or  larger  segment 
in  the  intestine. 

ment,  the  other  opposite.  The  mesenteric  suture  should  close 
the  little  triangle  where  the  mesentery  is  reflected  from  the  gut. 
Leave  the  long  ends  of  the  sutures  intact.  Pass  them  up  the 
lumen  of  the  proximal  portion  of  the  bowel  and  out  through  a 
longitudinal  slit  previously  made  in  its  wall  opposite  the  mesen- 
tery, and  about  an  inch  from  its  cut  end  (Fig.  131).     Draw  on 


maunsell's  method. 


385 


the  sutures,  and  the  distal  or  smaller  end  g  (Fig.  133)  will  be 
invaginated  into  the  proximal  or  larger  end  h,  and  thence  pulled 
out  of  the  longitudinal  incision  in  the  wall  of  the  proximal  portion 
H.  From  Fig.  132  it  will  be  seen  that  the  serous  surfaces  of  the 
two  portions  are  in  accurate  apposition  all  round.  Whilst  an 
assistant  holds  up  the  intestine  by  the  temporary  sutures,  drawing 
them  gently  apart  so  as  to  render  the  lumen  of  the  invagination 
an  oval  slit,  pass  a  straight  needle  armed  with  fine  silk  across  the 
slit  a  quarter  of  an  inch  from  the  cut  ends  through  the  whole 
thickness  of  the  four  walls  of  the  intestine  (Fig.  133).     Hook  up 

Fig.  132. 


Maunsell's  method  of  circular  enterorrhaphy.     G.  The  interior  of  the  distal  portion.     H.  The 
interior  of  the  proximal  portion  of  the  bowel. 

Fig.  133. 


Maunsell's  method  of  circular  enterorrhaphy.     o.  The  distal  portion.     H.  The  pro.ximal  por- 
tion of  the  intestine,     a.  The  needle  in  transit. 


the  suture,  divide  it  and  tie  each  half.  In  this  way  twenty  sutures 
can  be  passed  in  ten  transits  of  the  needle.  When  sufficient 
sutures  have  been  applied,  cut  short  the  temporary  sutures  and 
reduce  the  invagination  by  traction  on  the  two  portions  of  the  gut 
17 


\S6 


INJURIES   OF   REGIONS. 


and  close  the  longitudinal  slit  by  a  continuous  Lerabert  suture. 
On  the  completion  of  the  operation  the  peritoneal  surfaces  are 
accurately  in  contact,  and  the  knots  are  all  inside   (Fig.  134). 


Fig.  134. 


U  ^L  U 


A^V/4ti 


;v 


Maunsell's  method  ot  circular  enterorrhaphy      Appearance  of  intestini.  at  (.onipletion  of  oper- 
ation.    G.  I)ibtal  portion,     n.  ProMiiial  portion  of  intestine. 

Maunsell  paints  the  wound  with  Wolfler's  mixture  of  alcohol, 
glycerine  and  colophonium,  and  dusts  it  with  iodoform.  The 
only  objection  to  the  method  is  the  infliction  of  the  longitudinal 
wound.  PauPs  method. — Insert  a  Paul's  decalcified  bone-tube, 
to  which  is  attached  a  needle  and  double  silk  ligature  to  form  a 
traction  thread  (Fig.  135),  into  the  proximal  end  of  the  intestine; 

Fig.  135. 


Paul's  bone-tube,  with  double  silk  ligature  for  forming  traction  thread  fixed  to  holes  in  the 
tube  at  3  3.     I.  Distal  end  perforated,  with  holes  for  sewing  to  bowel.     2.  Needle. 

sew  this  end  of  the  intestine  to  the  tube,  closing  the  triangular 
interval  at  the  mesentery.  Pass  the  needle  and  traction  thread 
through  the  lumen  of  the  distal  portion  of  the  intestine,  and  bring 
it  out  through  the  wall  three  inches  down  (Fig.  136)  ;  unite  the 


Fig.  136. 


Gut  ready  for  invagination  in  Paul's  method  of  enterorrhaphy.     i.  Proximal  end  of  gut,  with 
tube  sewn  in.     2.  Distal  end,  with  traction  thread  {3)  passed  through  its  wall. 


INTESTINAL   ANASTOMOSIS, 


3S7 


cut  ends  of  the  bowel  by  continuous  suture  ;  draw  on  the  traction 
thread,  and  thus  invaginate  the  upper  into  the  lower  portion,  be- 
ginning the  invagination  immediately  below  the  line  of  union  ;  fix 
the    invagination    by   Lembert's    sutures    (Fig.    137).     Pull   the 


Condition  of  parts  in  Paul's  method  of  enterorrhaphy  when  operation  is  completed,     i.  The 
intussuscipiens.     2  2.  Lembert's  sutures. 

traction  thread  tight ;  cut  it  off,  and  allow  ends  to  pass  back  into 
the  bowel.  The  condition  of  the  parts  at  the  end  of  the  opera- 
tion is  seen  on  section  in  Fig.  138.  The  bone-tube  is  disinte- 
grated and  passed  per  anum. 

Intestinal  anastomosis,  or  the  restoration  of  the  continuity  of 
the  intestine  after  complete  division  or  excision  of  a  portion,  may 
be  done  by  Senn's  plates  and  Muiphy's  button.  Semi's  Method. 
— Having  let  what  faeces  will  escape  from  the  proximal  portion  of 
the  intestine,  clamp  both  the  proximal  and  distal  portions  about 
five  inches  above  and  below  the  divided  spot  by  passing  a  piece 


Section  of  parts  shown  in  Fig.  137.     i.  Bone-tube.     2.  Traction  thread  cut  short.     3.  Proxi- 
raaf  end  of  bowel.     4.  Distal  end  invaginated. 


of  India-rubber  tubing  through  a  small  incision  in  the  mesentery 
and  tying  it  sufficiently  tightly  to  prevent  any  further  faecal  soiling 
of  the  parts,  or  if  the  rubber  tubing  is  not  at  hand  the  bowel  may 
be  clamped  by  a  large  safety-pin.  Invaginate  the  divided  ends 
with  the  peritoneal  surfaces  in  contact  and  unite  them  by  a  con- 
tinuous suture  passed  through  the  peritoneal  and  muscular  coats 
(Fig.  139,  A  a).  Make  an  incision  about  an  inch  in  length  along 
the  convexity  of  each  portion  of  the  intestine  between  the 
sutured  end  and  the  rubber  clamp.  Insert  into  each  incision  a 
Senn's  bone-plate  properly  threaded,  as  shown  in  Fig.  141,  with 
four  fine  aseptic  china  silk  sutures.     Pass  the  lateral  sutures  from 


388 


INJURIES   OF   REGIONS. 


within  outwards  through  all  the  coats  of  the  intestine  a  line  or 
two  from  the  margin  of  the  incision,  and  bring  the  longitudinal 
sutures  out  through  each  end  of  the  incision   (Figs.  139,  140). 

Fig.  139. 


Method  of  forming  an  intestinal  anastomosis  by  Senn's  bone-plates  after  complete  division  of 
the  bowel.     The  divided  ends  closed  by  a  continuous  Lembert's  suture,  A  A. 


Fig.  140. 


Di.ngram  of  intestine  united  by  Senn's  plates.  The  arrow  shows  the  way  in  which  the  con- 
tents of  the  bowel  pass  ihrough  the  plates  and  incision  in  the  wall  of  the  bowel  from  the 
proximal  into  the  distal  portion. 

Now  place  each  portion  of  the  intestine  corresponding  to  the 
situation  of  the  bone- plates  opposite  to  each  other,  and  having 
scarified  the  serous  surfaces  lightly  with  the  point  of  a  needle  to 
aid  subsequent  adhesion,  tie  each  of  the  four  sutures  coming  from 
one  bone-jjlate  to  the  corrcs|)onding  suture  from  the  other,  just 
sufficiently  tightly  to  keep  the  wall  of  the  intestine  between  the 
plates  in  contact.     Tuck  in  the  knots  between  the  approximated 


INTESTINAL  ANASTOMOSIS. 


389 


serous  surfaces  and  apply  round  the  line  of  approximation  for 
greater  safety  an  omental  graft  (Fig.  142;.  On  removing  the 
clamps  the  contents  flow  as  shown  by  the  arrow  in  Fig.  140, 
through  the  central  hole  in  the  bone-plates  and  the  incision  in  the 
walls  of  the  gut  from  the  proximal  to  the  distal  portion  of  in- 
testine. The  bone-plates  hold  the  portions  of  intestine  in  contact, 
preventing  any  leakage  of  feeces  till  firm  union  has  occurred. 
They  ultimately  become  dissolved,  and,  together  with  the  sutures, 
are  passed  per  anum.  The  advantages  of  this  method  over  circu- 
lar enterorrhaphy  as  practised  by  the  Lembert  and  Czerny- 
Lembert  suture  are  that  it  can  be  done  in  a  much  shorter  time  (a 
quarter  of  an  hour?),  and  hence  greatly  minimizes  the  risk  from 
shock.  It  also  appears  attended  with  less  danger  of  septic 
peritonitis,  from  the  possibility  of  leakage  between  the  sutures  or 
the  penetration  of  the  mucous  coat  by  one  of  the  Lembert 
stitches. 

The  omental  graft  is  made  by  cutting  a  piece  of  omentum 
about  an  inch  wide  sufficiently  long  to  encircle  the  intestine 
(Fig.  142).     It  is  placed  over  the  line  of  union  and  fixed  by  cat- 


FiG.  141. 


Fig.  142. 


A  Senn's  decalcified  bone-plate  threaded 
ready  for  use.  A  fine  china  silk  suture 
with  a  loop  at  one  end,  the  size  of  the 
aperture  in  the  plate,  is  passed  through 
one  of  the  suture  holes,  and  to  this  loop 
the  three  other  sutures  passed  through  the 
three  remaining  holes  are  securely  tied. 
The  plates  should  be  kept  in  alcohol. 


Portion  of  intestine  with  line  of  suture  cov- 
ered by  omental  graft,  i.  Intestine.  M. 
Mesentery.  o.  Graft,  s.  Suture  fi.xing 
graft. 


gut  sutures  to  the  mesentery,  the  stitches  being  parallel  to  the 
mesenteric  vessels.  It  adheres  very  rnpidly  to  the  intestine,  but 
this  adhesion  may  be  accelerated  by  lightly  scarifying  the  peri- 
toneal coat  of  the  intestine  to  which  the  graft  is  to  be  applied. 


390 


INJURIES    OF    REGIONS. 


It  is  of  sen-ice  in  preventing  extravasation  should  a  leakage  occur 
through  a  stitch-wound,  etc. 

Alurphys  method  of  uniting  completely  divided  intestine  by  an 
anastomosis  button. — By  this  contrivance  an  end-to-end  approxi- 
mation or  a  lateral  anastomosis  may  be  quickly  accomplished  with- 
out sutures.  The  button  consists  (Fig.  143)  of  two  halves.  The 
male  half  a  has  a  spring  flange  p  for 
keeping  up  pressure  on  the  approxi- 
mated intestine.  The  two  springs 
J  s,  projecting  through  openings  in 
the  hollow  stem,  act  as  the  male 
thread  of  a  screw  when  the  shank 
is  telescoped  within  the  stem  of 
the  female  half  b.  The  intestine 
having  been  clamped,  as  previously 
described,  pass  the  running  thread 
(Fig.  144)  by  the  overhand  stitch 
{b)  round  the  cut  end  of  the  irites- 
tine,  beginning  and  ending  opposite 
the  mesenteric  attachment.  One  re- 
turn stitch  {a)  should  be  taken  at 

Fig.  143. 


Miirnhy's  lUitton.  A.  Male  half.  n.  Female 
half.  p.  Sprlne  flange,  .y  j.  Springs  projecting 
through  openings  in  h(  How  stem.  Part  of  the 
cap  of  the  male  half  has  been  cut  away  at  r  to 
show  circular  spring  which  acts  on  flange.  The 
round  holes  in  the  caps  are  for  drainage. 


M<:lhi)d  of  applying  "  puckering 
thread"  {b)  preparatory  to  inserting 
the  button.  At  n  the  method  of  ap- 
plying the  return  stitch  so  as  to  close 
the  triangular  interval  ic)  at  the  re- 
flection of  the  mesentery  is  shown. 


the  merjenteric  attachment  to  close  the  triangular  interval  {c)  which 
exists  at  the  reflection  of  the  mesentery  from  the  gut.  Insert  one- 
half  of  the  button  in  the  end  thus  jjrcpared,  tighten  the  running 
thread  so  that  the  intestine  is  puckered  uj)  round  the  stem  of  the 
button,  tie  the  ends  of  the  thread  and  cut  them  short.  Secure 
the  other  half  of  the  button  in  a  like  manner  in  the  other  end  of 
the  intestine  (Fig.  145).     The  method  of  holding  the  button  dur- 


INTESTINAL   ANASTOMOSIS. 


391 


ing  insertion  is  shown  in  Figs.  147,  148.     Press  the  two  halves 
together,  and  the  peritoneal  surfaces  are  held  in  close  and  accurate 


Fig.  145 


-'^- 


i\Iurphy's  method  of  end-to-end  approximation  of  divided  intestine.  The  male  and  female 
halves  of  the  button  are  secured  in  the  ends  of  the  divided  gut  by  the  "  puckering 
threads,"  and  ready  to  be  pressed  the  one  into  the  other. 

Fig.  146. 


To  show  the  method  of  passing  the  running  thread  for  fixing  the  half-button  in  Murphy's 
method  of  lateral  anastomosis  of  intestine. 

contact.  The  great  advantage  of  the  operation  is  the  rapidity  and 
ease  with  which  the  union  of  the  intestine  can  be  effected.  The 
disadvantages  are — i.  That  a  large  foreign  body  is  left  in  the  intes- 

FlG.  147. 


Showing  method  of  holding  male  half  of  button  for  insertion. 


tine,  where  it  may  become  a  source  of  danger  during  its  passage 
to  the  rectum,  and  2.  That  since  the  button  frees  itself  by  causing 


392  INJURIES    OF    REGIONS. 

gangrene  of  the  compressed  portions  of  intestine,  whilst  the  ad- 
hesion of  the  serous  surfaces  occurs  outside  the  grasp  of  the 
instrument,  there  is  perhaps  a  risk  of  the  gangrene  spreading  too 


Showing  method  of  holding  female  half  of  button  for  insertion. 

far  and  of  perforation  or  non-union.  However,  whilst  condemned 
by  some  surgeons  the  method  is  highly  spoken  of  by  others  who 
have  used  it.  The  technique  of  lateral  anastomosis  with  Murphy's 
button  is  similar  to  that  of  the  end-to-end  approximation,  and 
requires  no  separate  description.     (See  Fig.  146.) 

III.  Penetrating  wounds  with  protrusion  but  without  injury 
OF  THE  viscera. — The  protruding  viscus  is  nearly  always  a  portion 
of  intestine  or  omentum.  It  should  be  cleansed  with  some  weak 
antiseptic  lotion,  and  returned  by  gentle  uniform  pressure  into  the 
abdomen,  care  being  taken  not  to  force  it  between  the  peritoneum 
and  fascia  transversalis.  If  the  wound  of  the  parietes  is  too 
small  to  allow  the  viscus  to  be  returned  easily,  it  should  be  cau- 
tiously enlarged.  The  wound  should  then  be  closed  in  the  way 
already  described.  If  the  portion  of  intestine  is  congested  or 
inflamed,  it  should  still  be  replaced.  If  gangrenous,  however,  it 
should  on  no  account  be  returned,  but  the  gangrenous  portion 
excised  and  the  continuity  of  the  gut  restored  by  one  of  the 
methods  already  described,  and  replaced  in  the  abdomen.  In 
exceptional  cases  it  may  be  left  /;/  situ,  an  incision  made  into  it, 
and  an  artificial  anus  thus  formed.  A  congested  portion  of 
omentum  should  be  ligatured  and  cut  off,  and  the  stump  returned  ; 
a  gangrenous  portion  should  be  cut  off,  and  the  stump,  which  is 
probably  already  adherent,  separated  from  the  parietes,  ligatured 
at  a  healthy  spot,  the  diseased  part  cut  away,  and  the  stump  re- 
turned. The  general  treatment  should  be  the  same  as  that  before 
described. 

IV.  PeNETRA'JING    wounds    with     r.OTH    PROTRUSION    AND    INJURY 

OF  'IHE  VISCERA. — The  protruded  viscus  is  nearly  always  a  portion 
of  the  small  intestine.  'i"he  wound  should  be  united  by  suture 
in  the  way  already  described^  and  the  intestine  then  replaced, 


TRAUMATIC    PERITONITIS,  393 

If  the  intestine  is  completely  divided  it  may  be  united  by  one  of 
the  methods  already  described,  and  returned  j  or  an  artificial 
anus,  under  some  circumstances,  may  be  made.  If  the  wound  is 
high  up  the  intestine  the  former  procedure  should  be  the  one 
adopted. 

Traumatic  peritonitis  may  be  set  up  by  any  of  the  injuries 
above  described,  and  may  either  remain  localized  as  a  simple  in- 
flammation to  the  neighborhood  of  the  wound  or  other  injury,  or 
as  is  more  frequently  the  case,  may  become  diffused  over  the 
whole  peritoneal  cavity,  when  it  assumes  a  septic  character,  and 
terminates  in  blood-poisoning  from  the  absorption  of  the  chemi- 
cal products  of  putrefaction. 

The  simple  localized  variety,  after  gluing  the  parts  together,  and 
thus  preventing  the  spread  of  the  inflammation,  usually  subsides ; 
but  it  may  terminate  in  suppuration  and  the  formation  of  a  cir- 
cumscribed abscess,  which  may  burst  externally,  into  the  intestine, 
or  into  the  general  peritoneal  cavity,  then  setting  up  diffuse  peri- 
tonitis. The  diffuse  variety  is  generally  due  to  extravasation  of 
urine,  blood,  bile,  or  the  contents  of  the  stomach  or  intestine,  or 
the  breaking  of  an  abscess  into  the  peritoneal  cavity  ;  and  when 
there  is  an  open  wound,  or  a  wound  or  rupture  of  the  bladder, 
stomach,  or  intestine,  it  assumes  a  septic  character.  It  usually 
terminates  fatally,  sometimes  in  a  few  hours,  usually  within  a  week 
or  ten  days,  either  from  collapse,  or  from  blood-poisoning  due  to 
the  absorption  of  septic  products.  Should  recovery  occur,  death 
may  subsequently  ensue  from  intestinal  obstruction  consequent 
upon  the  gluing,  together  of  the  intestines  or  the  strangulation  ot 
a  loop  by  a  band  of  adhesion. 

Symptoms. — In  the  local  fo7-m  there  is  severe  pain  at  one  part 
of  the  abdomen,  increased  on  pressure,  on  deep  inspiration,  and 
on  coughing,  with  perhaps  vomiting,  and  a  slight  rise  of  tempera- 
ture, followed  should  an  abscess  form  by  a  circumscribed  swelling, 
rigors,  and  fever.  In  the  diffuse  variety  the  pain,  which  at  first 
may  be  localized  to  the  seat  of  wound  or  injury,  becomes  general 
and  of  a  lancinating  character,  and  so  increased  by  the  slightest 
pressure  that  the  weight  of  the  bedclothes  in  a  severe  case  cannot 
be  borne.  The  patient  lies  on  his  back  with  his  legs  drawn  up  to 
relax  the  abdominal  parietes,  his  breathing  being  entirely  thoracic. 
The  abdomen  is  at  first  hard,  owing  to  the  spasmodic  contraction 
of  the  muscles,  but  soon  becomes  distended  and  tympanitic,  the 
paralysis  of  the  muscular  coat  of  the  intestines  allowing  them  to 
become  inflated  with  gas.  Later,  as  effusion  occurs,  the  abdomen 
becomes  dull  in  the  flanks.  The  general  symptoms  are  obstinate 
vomiting,  usually  constipation,  hiccough,  a  furred,  dry,  and  brown 
tongue,  a  small,  quick,  and  wiry  pulse,  and  exhaustion  and  col- 


394  INJURIES    OF    REGIONS. 

lapse.  The  temperature  may  register  103°  or  104°,  but  it  gener- 
ally falls  before  death,  or  may  remain  little,  if  at  all,  raised 
throughout. 

The  treatment  may  be  divided  into  the  preventive  and  the 
curative.  Preventive  treatment  consists  in  the  prompt  removal, 
where  practicable,  of  the  conditions  which,  if  allowed  to  continue, 
are  virtually  certain  to  be  followed  by  inflammation  ;  and  subse- 
quently in  keeping  the  patient  at  absolute  rest,  and  allowing 
nothing  to  be  taken  by  the  mouth  save  small  quantities  of  ice 
or  hot  water.  By  most  Surgeons  opium  in  small  and  repeated 
doses  is  given ;  but  by  others  the  drug  is  only  used  if  there  is 
much  pain,  as  it  tends  to  restrain  absorption  from  the  peritoneal 
surface,  and  excretion  from  the  intestines.  Mr.  Tait,  on  the  first 
signs  of  peritonitis,  orders  a  turpentine  enema  and  a  saline  pur- 
gative, with  a  view  to  causing  the  absorption  of  any  serum  that 
may  have  collected  in  the  peritoneum.  This  treatment  is  advan- 
cing in  favor,  but  it  should  be  borne  in  mind  that  it  ought  never 
to  be  employed  when  there  is  any  serious  obstruction  in  the  intes- 
tine ;  in  such  cases  it  could  only  do  harm.  Where  the  abdomen 
has  been  closed,  as  after  an  ovariotomy,  the  wound  may  at  times 
be  opened  with  advantage,  the  peritoneum  washed  out  and  a 
glass  drainage-tube  inserted.  In  the  way  of  curative  treatment 
the  only  chance  for  the  patient,  where  the  inflammation  depends 
on  such  causes  as  those  above  mentioned,  is  at  once  to  freely 
open  the  abdomen,  deal  with  any  wounded  viscus  in  the  way 
already  described,  let  out  the  gas  from  each  distended  coil  by 
puncture  with  a  fine  trocar  and  cannula,  and  faeces  through  a  tem- 
porary incision,  thoroughly  irrigate  the  peritoneal  cavity,  and 
establish  a  free  drain.  Exhaustion  and  collapse  should  be  met  by 
strychnine  and  brandy  before  the  operation,  and  afterwards  by 
warmth,  stimulants  and  nutrient  enemata.  In  the  local  variety, 
leeches,  followed  by  hot  fomentations  and  turpentine  stupes,  may 
be  employed,  whilst,  should  suppuration  occur,  the  pus  should  be 
cautiously  let  out. 

INJURIES    or    THE    PELVIS. 

Fractures  of  the  pelvis. —  Cause. — Nearly  always  severe  and 
direct  violence,  as  the  passage  of  the  wheel  of  a  heavy  van,  or  a 
crush  between  the  buffers  of  railway  carriages.  The  acetabulum, 
however,  especially  in  old  ])eo[jle,  may  be  fractured  from  a  fall 
on  the  great  trochanter,  or  its  rim  may  be  chipped  off  in  conjunc- 
tion with  dislocation  of  the  hip. 

State  of  the  parts. — The  injury  may  be  localized  to  the  aceta- 
bulum, or  to  the  ramus  of  the  pubes  or  ischium ;  or  merely  the 


FRACTURES    OF   THE    PELVIS. 


395 


Fracture  of  the  pelvis.     (Bryant's  Surgerj\) 


anterior  -superior  iliac  spine  or  the  crest  of  the  ilium  may  be 
splintered  off.  When  the  result  of  a  crush,  the  injury  is  generally 
more  severe,  the  line  of  fracture  often  extending  through  the 
ramus  of  the  pubes  or 

ischium,    and    thence  Fig.  149. 

backwards  through  the 
ilium  near  the  sacro- 
ihac  synchondrosis, 
thus  detaching,  as  it 
were,  one  side  of  the 
pelvis  from  the  other. 
Or  the  fracture,  as 
shown  in  Fig.  149,  may 
extend  in  various  di- 
rections, more  or  less 
smashing  both  the 
false  and  true  pelvis. 
The   fracture   owes  its 

importance  to  the  hability  of  the  pelvic  viscera  to  be  injured. 
Thus  the  bladder  is  not  infrequently  ruptured;  or  the  urethra 
torn  across  by  a  fragment  of  the  pubic  arch  ;  or  the  rectum  or 
intestines  lacerated  when  the  sacrum  or  the  venter  of  the  ilium  is 
implicated. 

Sig/?s. — The  history  of  the  accident,  and  perhaps  the  mark  of  a 
wheel  across  the  lower  part  of  the  body,  will  commonly  direct 
attention  to  the  possibility  of  a  fracture.  On  grasping  the  crests 
of  the  ilia  firmly,  preternatural  mobility  or  crepitus  may  be  dis- 
covered and  pain  produced,  whilst  the  patient  is  usually  unable  to 
walk  or  to  turn  himself  in  bed  without  great  suffering.  A  dis- 
placed fragment  may  sometimes  be  felt  through  the  vagina  or 
rectum.  There  is  usually  considerable  shock,  and  where  any  of 
the  viscera  have  been  ruptured,  commonly  severe  collapse.  (See 
Ritpiure  of  Bladder-,  Urethra,  etc. ) 

Treatment. — As  the  bone  readily  unites,  little  beyond  keeping 
the  parts  at  rest  and  in  apposition  is  required.  This  may  be  done 
by  applying  a  flannel  bandage  firmly  round  the  pelvis  and  confin- 
ing the  patient  to  bed  for  three  to  five  weeks,  according  to  the 
severity  of  the  fracture.  Where  there  has  been  much  ciushing  a 
gutta-percha  or  poroplastic  felt  shield  should  be  moulded  to  the 
pelvis  and  hip  of  the  affected  side,  to  prevent  any  movement  of 
the  fragments  by  the  use  of  the  joint.  In  any  case  a  catheter 
should  be  passed  in  order  to  make  sure  that  the  urinary  apparatus 
is  not  injured. 

Fracture  of  the  acetabuliiin. — A  word  or  two  in  addition  may 
be  said  of  this  form  of  fracture  of  the  pelvis.     The  rim  of  the  ace- 


396  INJURIES   OF   REGIONS. 

tabulum,  generally  the  posterior  and  upper  part,  may  be  broken 
off  in  some  forms  of  dislocation  of  the  femur  on  to  the  dorsum 
ilii.  Besides  the  ordinary  symptoms  of  the  dislocation,  crepitus 
will  generally  be  detected  on  manipulation,  and  the  head  of  the 
femur  will  slip  in  and  out  of  the  acetabulum.  Or  the  fracture 
may  extend  through  the  floor  of  the  acetabulum,  the  head  of  the 
bone  being  even  driven  into  the  pelvis.  Crepitus  may  then  be 
detected  ;  or  the  head  of  the  bone  may  be  immovably  fixed  and 
the  limb  shortened.  Pain  is  present  on  movement  or  on  attempt- 
ing to  stand  on  the  limb  ;  also,  it  is  said,  on  pressing  on  the 
pubes.  Treatment. — Extensipn  may  be  made  by  a  long  splint,  or 
by  a  stirrup,  weight  and  pulley. 

Rupture  of  the  bladder  can  only  occur  when  the  viscus  is  full. 
It  may  then  be  due  to  a  blow  or  kick  upon  the  abdomen,  and  is 
a  frequent  complication  of  fracture  of  the  pelvis.  Rupture  is 
seldom  due  to  over-distension  consequent  upon  urethral  stricture, 
as  the  walls  of  the  bladder  are  then  generally  thickened  and 
thereby  rendered  capable  of  resisting  the  pressure  of  the  contained 
urine.  Under  these  circumstances  it  is  commonly  the  urethra  be- 
hind the  stricture  that  gives  way. 

State  of  the  parts. — The  rupture,  which  is  usually  vertical,  may 
extend  through  the  posterior  part  ot  the  bladder,  the  urine  escap- 
ing into  the  peritoneal  cavity,  or  through  the  anterior  part,  the 
urine  then  being  extravasated  into  the  loose  cellular  tissue  of  the 
pelvis.  In  the  former  case,  which  is  the  more  common,  acute 
peritonitis  is  generally  setup,  and  is,  as  a  rule,  fatal  in  a  few  days. 
In  the  latter,  diffuse  cellulitis  commonly  occurs,  the  patient  suc- 
cumbing either  to  septic  poisoning  from  the  absorption  of  the 
products  of  putrefaction,  or  to  the  extension  of  the  inflammation 
to  the  peritoneum. 

Signs. — Intense  collapse  following  a  blow  over  the  abdomen  or 
a  severe  injury  of  the  pelvis,  combined  with  the  fact  that  on  pass- 
ing a  catheter  (as  should  always  be  done  in  such  a  case)  no  urine 
but  only  a  little  blood  escapes,  whilst  the  patient  states  that  the 
bladder  was  full  at  the  time  of  the  accident,  or  at  least  that  he  had 
passed  no  water  for  several  hours  previously,  should  lead  us  to  in- 
fer that  the  bladder  is  ruptured.  The  catheter,  moreover,  may  at 
times  be  felt  to  be  grasped  by  the  empty  bladder,  and  to  slip 
through  the  rent  in  its  walls  ;  the  point  may  then  be  detected 
more  plainly  than  natural  through  the  front  of  the  abdomen,  and 
blood-stained  urine  may  flow.  'I'he  flow,  however,  is  not  con- 
tinuous, but  varies  with  respiration.  If  the  urine  has  had  time  to 
collect  in  the  peritoneum,  a  sensation  of  fluid  in  the  abdomen 
may  be  detected  on  palpation.  The  signs,  however,  are  not 
always  so  obvious.     Thus,  there  may  be  neither  collapse  nor  pain  ; 


RUPTURE  OF  THE  BLADDER.  397 

or,  again,  on  passing  a  catheter,  several  ounces  of  clear  urine  may 
escape,  owing  to  urine  having  collected  in  the  bladder  in  conse- 
quence of  the  rent  being  small  or  blocked  by  a  portion  of  in-  ^^  ^lU^^i 
testine.  If  in  doubt,^io*^r  12  ounces  of  some  antiseptic  fluid 
may  be  injected  into  the  bladder,  when,  if  no  rupture  exists,  the 
same  quantity  should  flow  out  again  through  the  catheter.  Or 
the  bladder  may  be  inflated  with  air  or  hydrogen  ;  if  there  is  a 
rupture,  the  abdomen  becomes  distended  and  the  liver  dulness 
lost ;  if  the  bladder  is  sound,  a  locahzed  tympanitic  tumor  rises 
from  the  pelvis.  Later,  symptoms  of  peritonitis  or  of  pelvic  cellu- 
litis will  probably  supervene. 

Treatment. — The  following  are  the  chief  plans  of  treatment  that 
have  been  adopted  : — i.  The  retention  of  a  soft  catheter  just 
within  the  bladder.     2.  Washing  out  the  bladder  and  adjoining 

Fig.  150.  Fig.  151. 


Method  of  applying  Lembert's  suture  in  ruptured  bladder.     (After  Sir  W.  MacCormac.) 

portion  of  the  peritoneal  cavity  with  an  antiseptic  solution  by  a 
catheter  passed  through  the  rent  in  the  viscus.  3.  Washing  out 
and  drainage  through  an  incision  in  the  perineum.  4.  Opening 
the  abdomen,  sewing  up  the  rent  in  the  bladder,  and  washing  out 
the  peritoneal  cavity  if  the  rupture  is  intra-peritoneal.  Of  these 
methods  the  last,  provided  every  care  is  taken  to  ensure  perfect 
closure  of  the  rent  in  the  bladder  and  thorough  cleansing  of  the 
peritoneum  by  irrigation,  holds  out,  in  the  intra-peritoneal  rupture, 
the  best  prospect  of  success.  Several  cases  have  now  been  treated 
successfully  in  this  way ;  amongst  the  first  of  these  may  be  men- 
tioned two  by  Sir  William  MacCormac,  one  by  Mr.  Holmes,  and 
one  by  myself.  In  sewing  up  the  bladder  the  peritoneal  surfaces 
should  be  brought  into  contact  by  Lembert's  sutures  (Figs.  150, 
151),  which  should  not  pass  through  the  mucous  membrane. 
And  one  suture  at  least  should  be  placed  beyond  the  angles  of  the 
wound  so  as  to  prevent  leakage  at  these  spots  (Fig.  150).  After 
the  rent  has  been  closed  an  antiseptic  fluid  should  be  injected 
into  the  bladder  to  make  sure  that  the  viscus  is  water-tight.  A 
catheter  should  not  be  tied  in,  for  fear  of  its  inducing  septic 


398  -  INJURIES   OF   REGIONS. 

changes  in  the  urine,  but  the  patient  should  be  made  to  regularly 
empty  his  bladder  every  four  hours  to  guard  against  over-dis- 
tension and  the  giving  way  of  the  sutures.  When  it  is  not  clear 
whether  the  rupture  is  intra  or  extra-peritoneal,  the  fundus  of 
the  bladder  should  be  exposed  before  opening  the  reflection  of 
the  peritoneum.  Extra-peritoneal  rupture  should  be  treated  by 
a  free  incision  in  the  perineum,  or  above  the  pubes,  and  an  anti- 
septic drain.  Nothing,  as  a  rule,  should  be  given  by  the  mouth 
for  the  first  twelve  or  twenty-four  hours.  Where,  however,  there 
is  extreme  collapse,  stimulants  may  be  cautiously  administered. 
As  in  other  peritoneal  cases,  it  is  a  moot  question  whether  opium 
should  be  used  as  a  matter  of  routine. 

Rupture  of  the  urephra  is  a  serious  injury,  as  it  exposes  the 
patient  not  only  to  the  immediate  danger  of  extravasation  of 
urine,  but  also  to  the  lifelong  trouble  of  a  traumatic  stricture.  It 
is  generally  caused  by  a  kick  on  the  perineum,  a  fall  astride  a 
joist  or  rail,  or  the  displacement  of  a  fragment  of  the  pubic  arch 
in  fracture  of  the  pelvis.  The  urethra  may  also  give  way  behind 
an  old  stricture  while  the  patient  is  straining  to  empty  his  bladder. 

State  of  the  parts. — The  rupture  usually  occurs  where  the 
urethra  passes  under  the  pubic  arch,  /.  e.,  either  just  in  front  of 
or  just  behind  the  triangular  ligament.  In  the  former  situation 
urine  and  blood  will  be  extravasated  in  the  perineum  ;  in  the 
latter,  about  the  neck  of  the  bladder.  As  the  triangular  liga- 
ment, however,  is  generally  torn,  some  urine  will,  as  a  rule,  in  the 
latter  case  also  pass  forward  into  the  perineum.  The  urethra 
may  be  completely  torn  across,  or  the  rupture  may  only  be 
partial,  the  upper  wall  escaping. 

The  signs  are  usually  quite  obvious.  Together  with  the  history 
of  an  accident,  there  will  be  pain,  swelling,  and  ecchymosis  of  the 
perineum,  and  escape  of  blood,  often  in  considerable  quantities, 
from  the  urethra.  The  patient  is  unable  to  pass  water,  and  any 
attempt  to  do  so  merely  forces  more  urine  into  the  tissues  of  the 
perineum,  and  gives  i)ain.  On  trying  to  pass  a  catheter  some 
obstruction  is  generally  met  with,  and  will  often  prove  insur- 
mountable ;  but  if  the  catheter  is  finally  passed,  clear  urine  will 
escape.  These  signs  distinguish  it  from  ruptured  bladder,  in 
which  injury  the  catheter  passes  easily,  but  as  a  rule  (although 
the  bladder  is  said  to  have  been  full  at  the  time  of  the  injury) 
only  a  little  urine  flows.  In  mere  bruising  and  ecchymosis  of  the 
perineum  the  catheter  will  pass  easily,  and  there  is,  as  a  rule,  no 
escape  of  blood  from  the  urethra. 

IVcatment. — A  soft  catheter  should  be  passed  if  possible ;  if 
not,  a  gum  elastic  or  a  silver  one,  and  in  any  case  tied  in.  Fail- 
ing to  pass  a  catheter  and  extravasation  of  urine  in  any  (piantity 


FOREIGN   BODIES   IN   THE   KECTUM.  399 

having  already  occurred,  a  silver  catheter  should  be  passed  down 
to  the  obstruction,  and  a  free  incision  through  the  middle  line  of 
the  perineum  made  on  its  point.  If  the  proximal  end  of  the  torn 
urethra  can  now  be  found,  the  catheter  should  be  passed  through 
it  into  the  bladder  and  tied  in.  If  now  readily  discovered,  a 
prolonged  search  for  it  need  not  be  made,  as  with  a  free  incision 
through  the  perineum  there  is  no  danger  of  further  extravasation 
of  urine.  If  the  urethra  is  found  only  partially  torn  across,  an 
attempt  should  be  made  to  bring  the  edges  together  by  suture 
over  a  catheter,  the  external  v/ound  in  the  perineum  being  then 
united  by  deep  sutures.  The  catheter  should  be  kept  in  for  a 
week.  In  a  recently  inflicted  injury,  in  which  the  urethra  was 
pulped  from  the  scrotum  to  the  prostate,  Mr.  Barnes,  of  Welwyn, 
succeeded  in  this  way  in  establishing  a  new  urethra,  the  wound 
healing  by  the  first  intention.  There  was  no  subsequent  trouble. 
This  procedure  is  attended,  however,  with  some  risk  of  extravasa- 
tion, and  could  hardly  be  done  where  extravasation  had  already 
occurred,  on  account  of  the  softened  condition  of  the  tissues. 
Should  a  fragment  of  the  pubic  arch  be  found  compressing  the 
urethra,  steps  must  be  taken  to  remove  it,  the  bladder  in  the 
meantime  being  aspirated  above  the  pubes  to  prevent  further  ex- 
travasation occurring.  When  the  wound  in  the  perineum  is  left 
to  granulate  in  the  ordinary  way  a  silver  catheter,  as  the  point  of 
this  is  more  under  control  than  that  of  a  soft  one,  should  be 
passed  daily  during  the  healing  of  the  wound,  and  the  patient  en- 
joined subsequently  to  pass  one  for  himself  at  frequent  intervals, 
and  warned  that  if  he  neglects  to  do  so  a  stricture  will  gradually 
form. 

Injuries  of  the  rectum  occasionally  occur  from  falls  upon  a 
sharp-pointed  body,  or  incautious  attempts  to  pass  a  long  enema- 
tube  or  bougie.  Should  the  peritoneal  cavity  be  perforated, 
death  is  the  almost  invariable  consequence,  especially  if  any  in- 
jection has  been  thrown  into  the  peritoneum  before  the  mistake  is 
discovered.  Treatment. — Opening  the  abdomen,  flushing  out  the 
peritoneum,  and  sewing  up  the  rent  in  the  gut,  holds  out  the  only 
chance  of  escape. 

Foreign  bodies  in  the  rectum. — Foreign  bodies  of  the  most 
various  description  have  at  times  been  accidentally  or  intention- 
ally introduced  into  the  rectum.  Fish-bones  that  have  been 
swallowed  not  infrequently  become  impacted  just  within  the  anus, 
there  giving  rise  to  much  irritation  or  pain,  and  often  causing  an 
ischio-rectal  abscess.  The  removal  of  some  of  these  bodies,  when 
of  large  size,  is  frequently  attended  with  considerable  difficulty, 
requiring  an  anaesthetic,  dilatation  of  the  sphincter,  and  the  use 
of  various  forceps,  or  even  the  passage  of  the  whole  hand.     In  a 


40P  INJURIES   OF   REGIONS. 

case  recently  under  the  care  of  Mr.  Willett,  the  foreign  body,  a 
Liebig's  meat  jar,  could  not  be  removed  till  the  peritoneal  cavity 
had  been  opened  and  the  jar  forced  down  by  the  hand. 

Injuries  of  the  pudenda. — Contusions  and  wounds  of  all  kinds 
may  be  met  with,  and  require  no  special  remark  further  than  : — 
that  ecchymosis  of  the  loose  cellular  tissue  is  often  extensive ; 
that  wounds,  though  apt  to  be  attended  with  considerable  haemor- 
rhage from  the  great  vascularity  of  the  parts,  on  this  account  also 
heal  very  readily  ;  and  that  serious  consequences  from  such  in- 
juries are  exceedingly  rare. 

H/EMATOMA  OF  THE  LABIA  MAjORA  sometimcs  occurs  from  injury, 
especially  during  pregnancy  or  parturition,  the  parts  being  con- 
gested at  those  times.  The  tumor  may  attain  a  large  size,  owing 
to  the  laxity  of  the  tissues.  The  blood  generally  becomes  ab- 
sorbed, but  suppuration  may  occur  or  the  blood  become  encysted. 
The  application  of  ice  will  generally  control  the  haemorrhage.  A 
hsematoma  should  on  no  account  be  opened  unless  suppuration 
takes  place,  when  a  free  incision  will  be  required. 

Wounds  of  the  vagina  perhaps  more  frequently  fall  under  the 
care  of  the  obstetrician  than  of  the  surgeon.  The  surgeon,  how- 
ever, may  be  called  upon  to  arrest  haemorrhage  from  this  canal, 
consequent  upon  laceration  inflicted  by  falling  upon  some  sharp 
object,  or  the  introduction  of  a  foreign  body.  Washing  out,  the 
application  of  ice,  or,  if  necessary,  careful  plugging  with  antiseptic 
gauze,  or  cotton-wood  soaked  in  perchloride  of  iron,  will  usually 
suffice. 

Perforation  of  the  walls  of  the  vagina,  with  injury  of  the 
bladder,  peritoneum,  or  intestines,  is  the  occasional  result  of 
wounds  of  the  vagina,  and  is  usually  fatal.  The  vagina  should  be 
washed  out  and  the  wound  plugged  with  strips  of  iodoform  gauze. 

Foreign  bodies  in  the  vagina. — Pessaries  that  have  been  in- 
troduced and  forgotten  by  the  patient,  or  possibly  without  her 
knowledge,  are  the  foreign  bodies  most  frequently  found  in  the 
vagina,  but  various  other  articles  have  at  times  been  met  with. 
Their  long  retention  here  is  often  productive  of  a  foul-smelling 
discharge,  and  may  lead  to  the  perforation  of  the  walls  of  the 
rectuni  or  bladder  and  an  incurable  fistula. 

FoRElCiN  bodies  in  THE  FEMALE  URETHRA  AND  BLADDER. Hair- 
pins introduced  with  the  bent  end  forwards,  are  not  infrequently 
pushed  up  the  urethra  into  the  bladder,  where,  if  allowed  to  re- 
main, they  become  encrusted  with  phosphates,  and  give  rise  to 
symptoms  of  stone.  The  urethra  should  be  dilated,  and  the 
sharp  ends  of  the  hair-i)in  grasped  by  forceps,  snared  in  a  tube, 
or  in  some  such  way  removed. 

RupiUKED    I'EKiNKUM    Occasionally    occurs    during    first,    and 


RUPTURED    PERINEUM. 


401 


especially  instrumental  labors.  There  may  be  a  mere  rent  in  the 
fourchette  ;  or  the  rupture  may  extend  from  the  vagina  through 
the  sphincter  ani  into  the  rectum,  and  involve  more  or  less  of  the 
recto-vaginal  septum. 

Symptoms. — A  rupture,  when  slight,  gives  rise  to  no  special 
trouble ;  but  when  more  extensive,  there  may  be  some  prolapse 
of  the  posterior  wall  of  the  vagina  with  the  contiguous  wall  of  the 
rectum  {recfocele),  or  of  the  anterior  wall  of  the  vagina  and  the 
part  of  the  bladder  in  contact  with  it  {vesicocele),  and,  perhaps 
some  prolapse  of  the  uterus.  There  may  also  be  frequent  micturi- 
tion, and  when  the  sphincter  ani  is  involved,  occasional  inconti- 
nence of  fccces. 

Treatment — An  attempt  to  unite  the  parts  should  always  be 
made  immediately  after  the  rup- 
ture by  introducing  several  wire 
or  silkworm-gut  sutures.  Should 
this  fail,  no  harm  will  have  been 
done,  and  a  plastic  operation 
can  be  subsequently  performed. 
Such,  however,  should  not  be 
undertaken  until  the  vaginal  dis- 
charge has  ceased,  the  child 
been  weaned,  and  the  general 
health  Restored.  The  patient  in 
the  meantime  should  not  be 
allowed  to  walk  about,  for  fear 
of  a  prolapse  of  the  parts.  The 
operation  consists  in  refreshing 
the  sides  of  the  rupture,  and 
uniting  them  by  suture.  The 
bowels  having  been  cleared  by 
an  aperient,  and  the  rectum  on 
the  morning  of  the  operation  by 
an  enema,  the  patient  should  be 
placed  in  the  lithotomy  position, 
and  the  skin  dissected  off  from 

the  sides  of  the  fissure,  and  the  mucous  membrane  from  the  recto- 
vaginal septum,  so  as  to  leave  a  raw  surface  of  the  size  and  shape 
shown  in  Fig.  152.  The  skin  and  mucous  membrane  should  not 
be  cut  away  as  shown  in  the  figure,  but  reflected  towards  the 
vagina.  Care  should  be  taken  that  the  tissues  are  clean  cut,  and 
that  the  raw  surface  of  the  recto-vaginal  septum  is  at  least  an  inch 
broad,  so  that  immediate  and  firm  union  when  the  parts  are 
brought  together  may  be  obtained.  Three  or  more  deep  sutures, 
consisting  of  thick  silver  wire,  strong  silkworm-gut,  or  China 
17* 


Operation  for  ruptured  perineum. 


402  INJURIES   OF   REGIONS. 

twist,  should  be  introduced  by  means  of  a  perineal  needle.  The 
first  should  be  passed  about  an  inch  from  the  margin  of  the  rup- 
ture deeply  through  the  recto-vagmal  septum,  and  out  at  the 
corresponding  spot  on  the  opposite  side.  The  next  two  sutures 
should  be  passed  in  the  same  way,  only  not  through  the  septum. 
Fig.  152  shows  the  appearance  presented  by  the  sutures  when  in 
situ  and  ready  for  tying.  They  may  be  fastened  over  a  piece  of 
quill  or  by  split  shot,  or  simply  tied,  the  posterior  suture  being 
first  secured.  Superficial  sutures,  after  the  fissure  has  been  drawn 
together  by  the  deep,  should  be  used  to  keep  the  edges  of  the 
skin  in  contact.  If  there  appears  to  be  any  tension,  "incisions 
of  relief  "  may  be  made  through  the  skin  on  either  side.  There 
are  many  modifications  of  this  operation,'  but  for  the  sake  of 
clearness  only  the  most  simple  method  has  been  here  described. 
The  bowels  must  be  kept  confined  for  a  week,  and  the  bladder 
for  the  same  period  emptied  by  the  catheter.  The  patient  should 
lie  perfectly  quiet  on  her  back  with  the  legs  tied  together,  and  the 
knees  over  a  pillow.  The  deep  sutures  should  be  removed  at  the 
end  of  a  week,  the  parts  in  the  meanwhile  being  kept  clean  by 
gentle  syringing  with  an  antiseptic  lotion.  The  bowels  should  be 
opened  by  an  enema  at  the  end  of  a  week  or  ten  days,  and  the 
patient  should  keep  her  bed  for  at  least  three  weeks.  Where  the 
posterior  or  anterior  wall  of  the  vagina  is  much  prolapsed,  a 
wedge-shaped  piece  of  mucous  membrane  may  be  remoVed,  and 
the  edges  of  the  incision  brought  together  by  suture. 

Injuries  of  the  scrotum  and  tesiicle. — Wounds  of  the 
scrotum  and  penis  are  rare.  They  readily  heal  in  consequence 
of  their  abundant  blood-supply.  Contused  wounds  of  the  scrotum 
are  often  attended  with  much  extravasation  of  blood,  giving  the 
parts  a  black  and  swollen  appearance,  and  are  apt  to  be  followed 
by  sloughing.  Sh'uild  such  threaten,  free  incisions  must  be  made. 
Extravasation  of  blood  into  the  tunica  vaginalis  {iucniiitoccle), 
and  inflammation  of  the  testicle  {orchitis),  both  of  which-  may 
follow  a  blow  or  other  injury  of  the  parts,  are  described  under 
Diseases  of  the  Testicle. 

Ligature  of  the  penis. — A  piece  of  string  is  sometimes  tied 
round  the  penis  by  children,  either  in  play,  or  to  prevent  them- 
selves wetting  the  bed.  Great  swellmg  in  front  of  the  constriction 
ensues,  and  if  the  cause  is  not  recognized  and  removed,  the 
string  will  soon  cut  deeply  into  the  penis,  and  may  even  divide 
the  urethra. 

FcjREIGN    I5f)DIES    IN    THE    MALE    URE'IHRA  AND    ni.ADDI'.K. — PicCCS 

of  slate  pencil,  beads,  and  the  like,  are  sometimes  passed  by  boys 
into  their  urethra,  and  not  infrcciuently  a  piece  of  wax  bougie,  or 
damaged  gum-elastic   or   black    catheter,   is  broken   off  during 


WOUNDS   OF   THE   PALM.  4O3 

catheterization.  An  attempt  should  be  made  to  remove  the 
foreign  body  by  manipulation  with  the  fingers,  or  by  the  intro- 
duction of  various  urethral  forceps,  or  by  asking  the  patient  to 
first  close  the  meatus  with  the  finger  and  thumb,  to  make  a  forci- 
ble attempt  to  pass  water,  and  then  suddenly  to  relax  his  hold. 
If  the  forceps  are  used  the  urethra  should  be  grasped,  if  practi- 
cable, behind  the  foreign  body,  lest  the  latter  be  pushed  back  into 
the  bladder.  Failing  to  remove  the  body  by  any  of  these  means, 
it  may  be  pushed  back  into  the  bladder,  broken  up  by  a  lithotrite, 
and  removed  by  the  evacuator,  or,  if  soft,  grasped  with  the 
lithotrite  and  removed  whole.  If  it  cannot  be  pushed  into  the 
bladder,  it  must  be  cut  down  upon  and  extracted  through  an  in- 
cision in  the  middle  fine  of  the  urethra.  A  pin  introduced  head 
first  may  have  the  point  thrust  out  through  the  skin  up  to  the 
head.  The  head  can  thus  be  reversed,  and  may  so  be  pushed 
out  through  the  urethra.  Foreign  bodies  in  the  bladder,  if  allowed 
to  remain,  become  encrusted  with  phosphates,  and  give  rise  to 
symptoms  of  stone  (see  Stone  in  the  Bladder) . 

INJURIES    OF   THE    UPPEK    EXTREMITY. 

Bruises,  contusions,  burns,  scalds,  and  frost-bites  of  the 
upper  extremity  require  no  special  remarks. 

Sprains  of  the  joints  of  the  upper  extremity,  especially  of  the 
wrist,  are  very  common.  Rest,  the  application  of  cold,  and  in 
the  case  of  the  thumb,  wrist,  or  elbow,  a  wet  bandage  followed 
by  friction  with  a  stimulating  liniment,  is  the  usual  treatment.  A 
sprain,  however  slight,  should  never  be  neglected,  as  inflamma- 
tion in  or  around  the  joint  may  ensue,  leading  to  fibrous  anky- 
losis, adhesion  of  the  tendons  to  their  sheaths,  etc.  See  Sprains, 
p.  186. 

Sprains  of  the  muscles,  causing  tenderness,  slight  swelling, 
and  pain  on  movement,  are  not  infrequently  met  with  after  hard 
rowing  or  other  excessive  exercise. 

Rupture  of  muscles  and  tendons,  especially  the  pectoralis 
major,  the  rectus  femoris,  and  the  long  tendon  of  the  biceps,  are 
not  uncommon  accidents.  The  last  may  occur  during  any  sud- 
den involuntary  action,  and  may  be  known  by  sudden  pain,  loss 
of  power,  and  a  gap  in  the  course  of  the  long  tendon,  whilst  the 
inner  head,  on  putting  the  muscle  into  action,  forms  a  prominent 
lump.     Little  or  nothing  can  be  done  in  the  way  of  treatment. 

Wounds  of  all  kinds  are  very  common.  Wounds  of  the  palm 
only  need  special  comment. 

Wounds  of  the  palm  are  frequently  attended  with  severe  and 
troublesome  haemorrhage  from  either  the  superficial  or  deep  arch. 


404 


INJURIES   OF   REGIONS. 


When  the  wound  is  clean  cut  the  bleeding  vessel  may  be  tied  in 
the  usual  way ;  but  when  the  wound  is  of  a  punctured  character 
such  an  attempt  would  inflict  severe  injury  on  the  tendons  and 
nerves  in  the  palm.  A  graduated  compress  in  this  case  should  be 
put  on,  the  hand  bandaged  over  an  ordinary  roller,  pressure  ap- 
plied to  the  ulnar  and  radial  arteries  at  the  wrist,  and  the  fore- 
arm flexed  forcibly  on  the  arm  to  control  the  flow  of  blood 
through  the  brachial  artery.  The  compress  should  be  kept  on 
for  about  a  week.  If  this  fails,  or  if  the  patient  is  not  seen  until 
the  palm  has  become  infiltrated  and  sloughy,  the  brachial  artery 
should  be  tied.  The  anastomosis  through  the  interosseous  and 
carpal  arteries  is  so  free  that  ligature  of  the  radial  and  ulnar  is 
not,  as  a  rule,  sufficient  to  stop  the  bleeding. 

Needle  in  the  palm. — It  is  not  infrequent  for  a  needle  to  run 
into  the  hand  and  be  broken  off.  If  it  can  be  felt  it  should  be 
cautiously  cut  down  upon  and  extracted  with  forceps,  care  being 
taken  not  to  push  it  in  further,  and  so  lose  it  in  the  attempt.  If 
it  cannot  be  felt,  an  exploratory  incision  should  on  no  account  be 
made,  as  the  needle  will  probably  do  no  harm  in  the  tissues,  and 
in  course  of  time  will  work  its  way  to  the  surface,  whilst  a  search 
for  it  may  be  attended  with  irreparable  damage.  A  galvanometer 
has  occasionally  been  used  for  its  discovery  with  success. 

In  smashes  of  the  hand  requiring  operative  interference,  the 
thumb  and  as  many  fingers — indeed  as  much  of  the  hand — as 
possible,  should  be  saved. 

Dislocations  of  the  Upper  Extremity. 

Dislocations  of  the  clavicle. — I.  The  sternal  end  may  be  dis- 
located, I,  forward  ;  2,  upwards  ; 
and,  3,  backwards.  Cause. — 
The  forward  and  the  upward 
dislocations  are  produced  by  in- 
direct violence,  such  as  a  blow 
or  fall  upon  the  front  or  top  of 
the  shoulder  ;  the  backward  vari- 
ety either  directly  by  force  ap- 
plied to  the  sternal  end,  or  indi- 
rectly by  a  blow  or  fall  on  the 
back  of  the  shoulder.  Displace- 
ment.— In  the  forward  disloca- 
tion the  end  of  the  bone  lies  in 
front  of  the  sternum,  in  the  up- 
ward  it  lies  in  the  suprasternal  notch  touching  the  opposite 
clavicle,  in  the  backward  between  the  sternum  and  the  trachea. 
Signs. — In  the  forward  dislocation  (I'ig.  153)  the  end  of  the  bone 


Fig. 


Dislocation  of  the  sternal  end  of  the  clavicle 
forwards.     (Bryant's  .Surgery.) 


DISLOCATION    OF    THE    CLAVICLE.  405 

can  be  felt  in  its  abnormal  situation,  and  can  be  distinguished 
from  fracture  near  the  sternal  end  by  the  length  of  the  clavicle 
being  the  same  on  the  two  sides,  and  by  the  absence  of  crepitus. 
The  upward  variety,  which  is  very  rare,  may  be  diagnosed  in  the 
same  way.  In  the  backward,  which  is  also  rare,  there  is  a  de- 
pression at  the  situation  of  the  sterno-clavicular  joint,  and  there 
may  be  dyspnoea,  dysphagia,  or  congestion  of  the  head  and  face 
from  pressure  on  the  trachea,  oesophagus,  or  veins  of  the  neck. 
Treattneiit. — The  forward  and  the  backward  dislocations  can  gen- 
erally be  readily  reduced  by  simply  drawing  back  the  shoulders, 
the  icnee,  if  necessary,  being  placed  between  the  scapulae.  In 
the  forward  variety,  indeed,  I  have  always  found  the  end  of  the 
clavicle  sink  into  its  place  on  laying  the  patient  on  his  back. 
Reduction  of  the  backward  variety  has  at  times  been  impossible, 
and  excision  of  the  end  of  the  bone  has  been  necessary  for  the 
rehef  of  the  severe  dyspnoea  which  it  has  caused  by  its  pressure 
on  the  trachea.  The  upward  dislocation  may  be  reduced  by 
placing  a  pad  in  the  axilla  to  act  as  a  fulcrum  and  pressing  the 
arm  to  the  side,  thus  drawing  the  clavicle  outwards.  Direct 
pressure  should  at  the  same  time  be  apphed  to  the  displaced 
end.  All  forms  are  difficult  to  retain  in  position.  The  best  plan, 
perhaps,  is  to  keep  the  patient  constantly  on  his  back  for  three 
weeks.  If,  however,  he  will  not  consent  to  this  restraint,  an 
endeavor  may  be  made  to  retain  the  parts  in  as  good  a  position 
as  possible  by  one  of  the  many  methods  of  bandaging  described 
in  the  larger  text-books.  I  do  not  mention  any  here,  as  I  have 
never  seen  any  of  them  of  any  avail. 

II.  The  acromial  end  may  be  dislocated  either,  i,  upwards; 
or,  2,  downwards.  Both  forms  are  rare,  but  the  upward  is  the 
least  so.  These  injuries  are  sometimes  spoken  of  as  dislocations 
of  the  scapula.  Cause. — Commonly  direct  violence  applied  to 
the  acromion.  The  signs  are  usually  obvious.  There  is  apparent 
lengthening  of  the  arm  with  depression  and  slight  flattening  of  the 
shoulder,  and  a  projection  in  the  region  of  the  acromio-clavicular 
joint  caused,  in  the  upward  form,  by  the  acromial  end  of  the 
clavicle,  and  in  the  downward  by  the  acromion  process.  In  the 
upward  variety,  moreover,  the  end  of  the  trapezius  stands  out  as 
a  prominent  ridge,  and  on  pressing  with  one  hand  on  the  shoul- 
der and  with  the  other  on  the  elbow  the  articular  surfaces  are 
brought  into  apposition  and  pseudo-crepitus  can  be  obtained. 
Reduction  is,  as  a  rule,  easily  effected  by  drawing  the  shoulders 
well  backwards  ;  but  it  is  difficult  to  retain  the  bones  in  position 
in  consequence  of  the  peculiar  obliquity  of  the  articulation.  This 
may  be  attempted  by  placing  a  pad  over  the  joint  and  applying  a 
strap  or  a  bandage  over  the  shoulder  and  under  the  elbow,  and 


406  INJURIES    OF    REGIONS. 

then  bandaging  the  arm  to  the  side.  I  have  seen  the  best  results 
from  rest  in  the  horizontal  position  for  three  weeks  ;  few  patients, 
however,  will  submit  to  this,  nor  is  it  possibly  worth  their  while  to 
do  so,  as  little  inconvenience  attends  the  dislocation,  though  un- 
reduced. 

Dislocation  of  ihe  shoulder  is  very  common,  a  fact  explained 
by  the  shallowness  of  the  glenoid  cavity,  the  large  size  and 
rounded  shape  of  the  head  of  the  bone,  the  looseness  of  the  cap- 
sule, and  the  powerful  leverage  exerted  on  the  joint  by  the  arm 
in  protecting  the  body  in  falls,  etc.  It  is  most  frequent  in  the  old 
and  middle-aged,  rare  in  the  young,  and  more  common  in  men 
than  in  women. 

Cause. — Falls  or  blows  directly  upon  the  shoulder ;  falls  on  the 
elbow  or  hand  with  the  arm  extended  ;  forcible  twists  of  the  arm  ; 
and  occasionally  muscular  action. 

Varieties. — Dislocations  of  the  shoulder  may  be  classified  ac- 
cording to  the  position  of  the  head  of  the  humerus  into — i,  for- 
ward and  slightly  downwards  {si/dcoracoid)  ;  2,  downwards  and 
slightly  forwards  {subglenoid)  ;  3,  backwards  {subspinous)  ;  and 
4,  forwards  {subclavicular)  (Figs.  154,  155,  156,  and  157).  An 
upward  dislocation  {subacromial)  has  been  described,  but  this 
form  of  displacement  is  more  generally  believed  to  be  the  result 
of  chronic  osteo-arthritis.  Other  and  rarer  varieties  have  also 
been  described,  but  appear  to  be  merely  modifications  of  those 
above  enumerated. 

The  signs  common  to  all  the  varieties  in  addition  to  the  ordi- 
nary signs  of  dislocation,  viz.,  pain,  swelling,  immobility,  and 
absence  of  crepitus,  are — i,  flattening  of  the  shoulder  ;  2,  promi- 
nence of  the  acromion ;  3,  a  depression  beneath  the  acromion, 
increased  when  the  arm  is  raised  ;  4,  a  change  in  direction  of  the 
axis  of  the  humerus  ;  and  5,  the  absence  of  the  head  of  the  bone 
from  the  glenoid  cavity,  and  its  presence  in  an  abnormal  situation. 
In  doubtful  cases  the  following  tests  will  be  found  of  use: — i, 
Hamilton'' s  test.  A  straight  edge  applied  to  the  outer  side  of  the 
arm,  can  only  be  made  to  touch  the  acromion  and  external  con- 
dyle at  the  same  time  when  the  head  of  the  humerus  is  absent 
from  the  glenoid  cavity;  2,  Calla7vafs  test.  A  tape  passed 
round  the  acromion  and  under  the  axilla  will  measure  about  two 
inches  more  on  the  dislocated  than  on  the  sound  side  ;  3,  Dugas's 
test.  With  the  hand  placed  on  the  opposite  shoulder,  the  elbow 
in  a  dislocation  cannot  be  made  to  touch  the  chest.  Occasionally 
a  dislocation  is  complicated  by  a  fracture,  and  an  accurate  diag- 
nosis may  be  rendered  very  difficult.  In  such,  and  in  all  cases 
where  there  is  any  doubt,  the  patient  should  be  examined  under 
an  anaesthetic. 


DISLOCATION    OF    THE    SHOULDER. 


407 


The  sitbcoracoid. — This  is  the  most  frequent  variety  of  disloca- 
tion of  the  shoulder  (Fig.  154)-  The  head  rests  on  the  anterior 
surface  of  the  neck  of  the  scapula,  just  below  the  coracoid  pro- 
cess, the  groove  between  the  head  and  greater  tuberosity  resting 
on  the  anterior  margin  of  th-e  glenoid  cavity.     The  capsular  liga- 


FlG. 


Fig.  153. 


tSu7)-ccj-acccd 


Fig.  156. 


Fig.  157. 


Sui-sp  incus 


jSuf?  - ,  rlavicular 


Various  forms  of  dislocalion  of  the  humerus.'    (Professor  Flower's  models.) 


-ment  is  lacerated,  anteriorly  and  inferiorly,  or  detached  from  the 
margin  of  the  glenoid  cavity  in  front  and  below.  The  subscapu- 
laris  is  generally  raised  by  the  head  of  the  bone  from  the  scapula, 
and  the  supraspinatus,  infraspinatus,  and  teres  minor  are  tightly 
stretched.     Sometimes  the  muscles  are  torn  across  at  their  inser- 


4o8  INJURIES   OF    REGIONS. 

tion,  or  the  greater  tuberosity  is  detached,  the  muscles  remaining 
entire.  Under  these  circumstances  the  head  of  the  bone  rolls 
inwards  so  that  more  of  it  is  internal  to  the  coracoid  process,  a 
condition  described  b}'  Malgaigne  as  a  distinct  variety  {intracora- 
coid).  The  long  head  of  the  biceps  is  generally  uninjured, 
whilst  the  short  head  and  the  coraco-brachiahs  and  the  axillary 
artery  and  brachial  plexus  are  displaced  inwards  by  the  head  of 
the  bone.  Special  signs. — The  head  of  the  bone  can  be  seen  and 
felt  in  its  abnormal  situation.  The  elbow  projects  slightly  back- 
wards and  away  from  the  side.  The  arm  is  generally  shortened 
or  unaltered  in  length  ;  occasionally  it  is  said  to  be  lengthened. 
The  truth  appears  to  be  that  there  are  all  grades  between  the 
subcoracoid  as  here  described,  in  which  there  is  undoubted 
shortening,  and  the  next  form,  the  subglenoid,  in  which  length- 
ening as  undoubtedly  occurs. 

The  subglenoid  is  the  next  most  common  variety.  The  head 
rests  on  the  inner  aspect  of  the  inferior  border  of  the  scapula,  be- 
low and  a  little  in  front  of  the  glenoid  cavity  (Fig.  155).  The 
capsular  ligament  is  ruptured  below.  The  supraspinatus,  in- 
fraspinatus, teres  minor,  and  subscapularis,  may  or  may  not  be 
torn.  The  circumflex  nerve  is  especially  liable  to  be  compressed, 
producing  temporary  or  even  permanent  paralysis  of  the  deltoid. 
The  signs  are  similar  to  those  of  the  subcoracoid,  but  there  is 
greater  flattening  of  the  shoulder,  more'  prominence  of  the 
acromion,  and  a  more  marked  depression  under  it,  and  the  elbow 
points  neither  backwards  nor  forwards.  The  diagnostic  marks 
are: — i,  great  depression  of  the  anterior  fold  of  the  axilla;  2, 
presence  of  the  head  of  the  bone  in  the  axilla ;  3,  lengthening  of 
the  arm  ;  4,  an  interval  of  from  one  to  two  inches  between  the 
coracoid  process  and  the  head  of  the  bone. 

The  subspinous. — This  variety  is  rare.  The  head  rests  on  the 
dorsum  of  the  scapula  beneath  the  spine  (Fig.  156).  The 
capsular  ligament  may  or  may  not  be  ruptured.  The  infraspi- 
natus is  generally  torn  up  from  the  bone,  and  the  subscapularis 
and  supraspinatus  are  either  stretched  or  ruptured,  according  to 
the  amount  of  displacement.  The  teres  minor  is  relaxed,  and 
the  long  tendon  of  the  biceps  stretched  or  displaced  from  its 
groove.  Special  signs. — There  is  great  flattening  of  the  shoulder  ; 
the  elbow  points  forwards  ;  -the  forearm  is  in  front  of  the  chest  in 
consequence  of  the  inward  rotation  of  the  humerus,  and  the  head 
of  the  bone  can  be  felt  in  its  abnormal  situation,  but  not  in  the 
axilla. 

The  subclavicular  is  very  rare.  The  head  rests  beneath  the 
clavicle,  internal  to  the  coracoid  process  (Fig.  157).  The  capsule 
is  generally  extensively  lacerated  at  its  inner  side.     The  pectoral 


•     DISLOCATION   OF  THE   SHOULDER.  409 

muscles  are  raised  by  the  head  of  the  bone,  which  rests  on  or  be- 
tween the  fibres  of  the  subscapularis.  The  latter  muscle  is  torn 
up  from  the  subscapular  fossa,  but  retains  its  connection  to  the 
humerus.  The  supraspinatus  and  infraspinatus  are  generally  torn, 
or  detached  from  the  humerus,  but  may  retain  their'  connection 
to  the  capsular  ligament.  The  teres  minor  is  not  torn.  Special 
sig?is. — The  head  of  the  bone  forms  a  distinct  prominence  below 
the  clavicle,  and  the  shaft  only  can  be  felt  in  the  axilla.  The 
arm  is  pressed  tightly  to  the  chest  and  the  elbow  projects  back- 
wards. 

Diagnosis. — A  dislocation  of  the  shoulder  may  have  to  be 
diagnosed  from  a  fracture  of  the  neck  of  the  humerus,  separation 
of  the  upper  epiphysis,  fracture  of  the  neck  of  the  scapula,  fracture 
of  the  glenoid  cavity,  and  from  simple  sprains  and  contusions  of 
the  joint  attended  with  more  or  less  paralysis  of  the  deltoid.  At- 
tention to  the  general  and  special  signs  of  dislocation  as  above 
given,  together  with  the  absence  of  crepitus  and  other  signs  of 
fracture,  will  generally  make  the  diagnosis  easy ;  but  where  the 
patient  is  very  muscular,  or  there  is  much  swelling,  or  manipula- 
tion causes  excessive  pain,  an  anaesthetic  should  be  given,  and  a 
thorough  examination  made.  It  should  not  be  forgotten  that 
crepitus  may  be  simulated  by  effusion  into  the  joint  and  sheaths 
of  the  surrounding  tendons.  True  bony  crepitus  having  been 
once  felt,  however,  can  hardly  be  mistaken  for  this. 

Treatment. — The  difficulty  in  reducing  a  recent  dislocation 
consists  in  i.  Overcoming  muscular  contraction,  and  2.  Re-intro- 
ducing the  head  of  the  bone  through  the  hole  in  the  capsule.  In 
long-standing  cases  there  are  additional  impediments  to  reduc- 
tion, viz.,  3.  The  formation  of  adhesions  around  the  joint;  4. 
Alteration  in  the  shape  of  the  head  of  the  bone,  and  5.  The  ob- 
literation of  the  old  cavity.  Manipulation  should  first  be  tried,  if 
necessary,  under  an  anaesthetic,  and  if  this  fails,  extension  should 
be  made  with  the  knee  or  heel  in  the  axilla,  and  finally  with  the 
pulleys.  In  some  long-standing  cases  where  the  above  methods 
have  failed,  reduction  by  open  incision  may  be  advisable,  i. 
Manipulation. — Many  methods  have  been  devised,  some  of  which 
are  not  unattended  with  danger,  as  the  axillary  artery  has  been 
torn  or  ruptured  in  their  use.  The  following  method  is  now  gen- 
erally employed  at  St.  Bartholomew's,  and  has  been  attended  with 
excellent  success.  Place  the  patient  in  the  horizontal  position ; 
flex  the  elbow  ;  rotate  the  humerus  outwards  as  far  as  possible 
without  using  excessive  force,  then  carry  the  elbow  across  the 
chest,  at  the  same  time  rotating  the  humerus  inwards.  Another 
method  consists  in  slowly  abducting  the  arm  to  the  level  of  the 
shoulder  or  above.  2.  Extension  (Fig.  158). — Place  the  patient 
18 


4IO 


INJL'RIES   OF   REGIONS. 


on  his  back ;  seat  yourself  on  the  edge  of  the  couch ;  draw  the 
arm  sliglitly  from  the  side  ;  place  your  heel  without  your  boot 
well  in  the  axilla,  and  grasping  the  wrist,  make  steady  extension 


Reduction  by  the  heel  in  the  axilla.     (Cooper's  Dislocations.) 


Fig. 


on  the  arm,  whilst  the  heel  fixes  the  scapula  and  presses  the  head 
of  the  bone  outwards.  The  head  of  the  bone  will  probably  be 
felt  after  a  few  minutes  to  shp  into  its  place  with  an  audible  snap. 
Should  it  not  do  so,  secure  a  jack-towel  with  a 
clove- hitch  (Fig.  159)  to  the  arm,  and  increase 
the  extending  force  by  getting  an  assistant  to 
pull  on  it  with  you  at  the  same  time.  The  di- 
rection of  the  force  may  be  slightly  varied  from 
time  to  time,  and  the  humerus  gently  rotated. 
Where  extension  with  the  heel  in  the  axilla  fails, 
slowly  carry  the  arm  to  a  right  angle  with  the 
body  and  extend,  or  raise  it  above  the  head,  and 
again  extend  in  this  position.  If  still  misuccessful,  an  anaes- 
thetic should  be  given,  and  the  bone,  on  again  trying  manipula- 
tion or  extension,  will  probably  slip  back  quite  easily  into  place. 
3.  Extension  with  the  pulleys. — In  long-standing  cases  the  use  of 
the  pulleys  may  be  required.  First  break  down  any  adhesions  that 
may  be  present,  by  cautiously  manipulating  the  arm  ;  then  fix  the 
scafiiila  by  a  well-jjadded  leather  strap  passed  under  the  axilla  and 
secured  to  a  staple  in  the  wall.  Attach  the  pulleys  to  a  leather 
band  buckled  round  the  arm,  and  make  steady  extension,  man- 


'J'hc  clove- 


DISLOCATION   OF   THE   SHOULDER. 


411 


ipulating  the  head  of  the  bone  the  while.  The  extension  and 
counter-extension  should  always  be  made  in  the  same  horizontal 
line.  This  may  be  first  in  the  direction  of  the  axis  of  the  body, 
then  across  the  body,  with  the  arm  at  right  angles  to  it  (Fig. 
160).  Occasionally  success  may  be  obtained  by  suddenly  relax- 
ing the  extension  after  it  has  been  applied  for  a  few  minutes, 
endeavoring  at  the  same  moment  to  manipulate  the  head  into  its 

Fig  160. 


Reduction  with  the  pulleys.  The  patient,  though  here  shown  pitting,  should  as  a  rule  be 
placed  in  the  recumbent  posture,  as  an  anaesthetic  is  generally  required.  (Cooper's  Dis- 
locations.) 


place.  Although  the  direction  of  the  force  appears  to  vary  in  the 
different  methods  of  extension,  it  is  probable  that  in  consequence 
of  the  mobility  of  the  scapula,  it  is  nearly  always  applied  perpen- 
dicularly to  the  plane  of  the  glenoid  cavity. 

Afier-ireatmcut. — A  pad  should  be  placed  in  the  axilla  and  the 
arm  carefully  bandaged  to  the  side  with  the  fore-arm  across  the 
chest,  and  the  hand  on  the  opposite  shoulder.  Passive  move- 
ments of  the  joint  should  be  begun  about  the  end  of  a  week  and 
practised  once  or  twice  daily  ;  but  the  arm  should  be  bandaged 
to  the  chest  in  the  intervals  for  upwards  of  three  weeks,  and  sub- 
sequently used  with  great  caution  for  several  months  to  prevent 
re-dislocation. 


412  .      INJURIES  OF   REGIONS. 

Occasional  ill-effects  following  a  dislocation  of  the  shoulder. — i. 
Inflammation  or  suppuration  of  the  joint  and  ankylosis  ;  2.  Paraly- 
sis of  the  deltoid  or  other  muscles ;  3.  Axillary  abscess ;  4.  Non- 
union of  the  rent  in  the  capsule  and  a  consequent  tendency  to 
re-dislocation  on  very  slight  violence. 

How  long  after  a  dislocation  of  the  shoulder  has  occurred  does 
it  admit  of  reduction  ?  Sir  Astley  Cooper  fixed  the  limit  at  three 
months,  but  cases  are  reported  in  which  it  is  said  to  have  been 
accomplished  two  years  after  the  accident.  It  should  be  re- 
membered, however,  that  as  in  unreduced  dislocations  a  new 
cavity  is  gradually  formed  for  the  head  of  the  bone  whilst  the  old 
cavity  is  filled  up,  reduction  sooner  or  later  becomes  a  physical 
i;r,poisibility.  Still,  where  the  arm  is  very  stiff,  although  reduc- 
tion may  not  be  accomplished,  the  range  of  motion  in  the  false 
joint  may  be  considerably  improved  by  the  attempt.  On  the 
other  hand,  where  the  motion  is  fairly  free,  the  injury  inflicted  in 
an  attempt  at  reduction  may  counterbalance  any  advantage 
gained. 

Risks  that  may  attend  reduction  of  long-standing  cases. — i. 
Rupture  of  the  axillary  artery  or  vein ;  2.  Injury  of  the  brachial 
plexus  of  nerves  ;  3.  Fracture  of  the  neck  of  the  humerus  ;  4. 
Fracture  of  the  ribs;  5.  Tearing  open  of  the  axilla;  and  6.  Evul- 
sion of  the  arm. 

4.  Reduction  by  open  incision. — This  method  has  been  recently 
employed  for  long  standing  cases  where  cautious  attempts  at 
reduction  by  manipulation  and  extension  have  failed.  The  ad- 
vantages claimed  for  it  are: — i.  That  the  reduction  can  be 
accomplished  without  subjecting  the  patient  to  the  dangers  men- 
tioned above,  and  2.  That  it  is  applicable  at  periods  later  than 
those  at  which  reduction  by  manipulation  or  by  extension  can  be 
accomplished  without  undue  risk.  An  incision  is  made  down  to 
the  head  of  the  bone  between  the  pectoralis  major  and  deltoid 
muscles,  and  the  subscapularis  muscle  detached  from  its  insertion 
into  the  lesser  tuberosity.  The  long  head  of  the  biceps  should 
be  preserved,  as  in  excision  of  the  joint.  If  the  bone  cannot  now 
be  manipulated  or  prized  by  an  elevator  into  position,  the  attach- 
ments of  the  external  rotators  (the  suprasi)inatus,  infraspinatus 
and  teres  minor)  are  in  like  manner  detached  from  the  greater 
tuberosity.  The  head  will  now  probably  return  into  its  socket, 
unless  the  time  that  has  elapsed  has  been  sufiicient  for  it  to  have 
been  partly  absorbed  and  the  glenoid  cavity  filled  up.  When, 
however,  the  head  cannot  be  replaced,  it  may  be  excised.  Passive 
movements  ought  to  be  begun  as  soon  as  the  wound  has  healed. 

Treatment  of  compound  dislocation  of  the  shoulder. — When  the 
wound  is  small,  the  head  of  the  bone  uninjured,  and  the  soft  parts 


DISLOCATION    OF    THE    ELBOW.  413 

are  neither  much  lacerated  nor  bruised,  an  attempt  should  be 
made  to  reduce  the  dislocation.  If  successful,  the  case  may  then 
be  treated  as  a  wound  of  the  joint.  When  the  head  of  the  bone  is 
much  injured,  it  may  be  excised  ;  whilst  in  severe  and  complicated 
cases,  amputation  at  the  shoulder-joint  may  become  necessary. 

The  treatment  of  dislocation  with  fracture  is  often  attended  with 
much  difficulty.  As  a  rule  the  fracture  if  possible  should  be  set, 
the  arm  placed  in  splints,  and  an  attempt  then  made  to  reduce 
the  dislocation.  Failing  in  this,  the  separated  head  may  some- 
times be  manipulated  into  its  socket ;  otherwise,  splints  should  be 
applied,  and  when  the  fracture  has  united,  another  trial  made  to 
reduce  the  dislocation. 
,  Dislocation  of  the  elbow  is  most  frequent  in  the  young. 
Cause. — Direct  violence,  or  a  fall  on,  or  wrench  of,  the  forearm 
or  hand. —  Varieties. — A.  Both  bones  (radius  and  ulna)  :  i,  back- 
wards ;  2,  inwards  ;  3,  outwards  ;  4,  forwards  ;  and  5,  radius  for- 
wards, and  ulna  backwards.  B. 
Radius  only :  i,  forwards  ;  2,  back-  ^^'^-  '^^'^• 

wards;  and  3,  outwards.  C.  Ulna 
^«/j'.-  I,  backwards.  Of  these,  the 
dislocations  of  both  bones  back- 
wards and  of  the  radius  forwards 
or  backwards  are  the  only  com- 
mon forms  ;  the  others  are  very 
rare,  and  will  receive  but  a  passing       ...       ,  ,        ,         ,   ,     ,    , 

Dislocation  of  the  radius  and  ulna  back- 
nOtlCe.  ward;.     (Cooper's  Dislocations.) 

Signs. — In  the  common  form 
of  doth  bones  backwai-ds  (Fig.  161),  the  radius  and  ulna  are  dis- 
placed directly  backwards,  so  that  the  coronoid  process  of  the 
ulna  rests  in  the  olecranon  fossa,  and  the  neck  of  the  radius  on 
the  capitellum  of  the  humerus.  The  coronoid  process  is  often 
fractured  at  the  same  time.  The  bones  are  frequently  displaced 
slightly  outwards,  or  inwards,  as  well  as  backwards — modifi;cations 
which  have  been  unnecessarily  classed  as  distinct  varieties.  The 
forearm  is  partially  flexed  and  shortened.  The  olecranon  and 
head  of  the  radius  form  an  unnatural  prominence  posteriorly,  and 
are  felt  at  a  considerable  distance  behind  the  external  and  internal 
condyles  respectively.  The  lower  end  of  the  humerus  forms  a 
broad  projection  below  the  crease  of  the  bend  of  the  elbovi^.  In 
the  rarer  forms  oi  both  bones  inwards  ox  outtvards  \.\\t.  prominence 
of  the  opposite  condyle  of  the  humerus  on  one  or  other  side  is  a 
characteristic  feature.  In  both  bones  forwards  (exceedingly 
rare)  the  forearm  is  lengthened,  the  natural  prominence  of  the 
olecranon  is  lost,  and  the  condyles  of  the  humerus  are  very 
prominent.  In  the  ulna  backwards  and  the  radius  forwards  the 
arm  is  greatly  increased  in  its  antero-posterior  diameter. 


414 


INJURIES    OF    REGIONS. 


In  dislocation  of  the  radius  alone,  whether  forwards,  backwards, 
or  outwards,  the  head  of  the  bone  is  felt  to  roll  in  its  abnormal 
situation,  in  front  of,  behind,  or  external  to,  the  external  condyle 
on  pronating  and  supinatinfT  the  hand.  The  first  of  these  forms 
(Fig.  162)  is  the  most  common,  and  in  it  the  forearm  cannot  be 
flexed  beyond  a  right  angle,  in  consequence  of  the  head  of  the 
bone  striking  the  humerus. 

///  dislocation  of  the  ulna  backwards  the  forearm  is  pronated 
and  shortened  on  the  ulnar  side,  and  the  olecranon  projects  back- 
wards, but  the  head  of  the  ndius  is  felt  in  its  normal  situation. 

Diagnosis. — In  moderately  thin  subjects,  when  seen  soon  after 
the  accident,  attention  to  the  above  signs  will  generally  enable  the 

Surgeon  to  make  a  diagnosis.; 
but  in  a  few  hours  the  parts 
become  so  obscured  by  swelling 
about  the  joint,  that  it  may  be 
impossible  to  make  out  the 
nature  of  the  injury  till  it  has 
subsided.  In  all  cases  of  injury 
of  the  elbow  the  relation  of  the 
points  of  bone  to  each  other 
should  be  carefully  compared 
with  those  of  the  uninjured  side, 
and  the  relative  position  of  the 
olecranon  to  the  condyles  should 
be  determined  {%&t  Fracture  of 
the  lower  end  of  the  Humerus). 
Treatment. — The  reduction  of  the  common  form  of  dislocation 
of  both  hones  baclnvards  is  generally  easily  accomplished  in  recent 
cases  by  pressing  with  the  knee  in  the  bend  of  the  elbow  on  the 
upper  part  of  the  radius  and  ulna  to  disengage  the  coronoid  pro- 
cess, whilst  forcibly  but  slowly  flexing  the  forearm.  As  soon  as 
the  coronoid  process  is  freed  from  the  olecranon  fossa,  the  muscles 
generally  draw  the  bones  suddenly  into  position.  Pressure  upon 
the  humerus  by  the  knee,  as  recommended  by  some,  should  be 
avoided,  as  it  locks  the  coronoid  process  more  tightly  in  the  ole- 
cranon fossa.  If  necessary,  an  ana2->thetic  should  be  given.  In 
long-standing  cases  adhesiors  mu.-t  be  broken  down  by  forcibly 
flexing  and  extending  the  forearm,  and  extension  may  then  be 
made  either  by  the  knee,  or  by  an  assiotant  pulling  on  the  wrist, 
or  if  this  is  insufficient,  bv  the  p'lUevs.  Six  weeks  is  the  period 
usually  given  as  the  time  beyond  which  it  is  inexpedient  to  try  and 
reduce  the  dislocation.  This  r"h%  however,  admits  of  some  lati- 
tude. Thus,  an  attempt  at  reduction,  when  the  movement  is  fairly 
good,  even  after  less  time  has  elapsed,  may  be  unwise  ;  while,  on 


Dislocation  of  the  radius  lorwartls. 


DISLOCATION    OF    THE    WRIST.  415 

the  other  hand,  it  may  sometimes  be  made  with  advantage,  espe- 
cially where  there  is  much  rigidity,  even  at  a  later  period.  In  dis- 
location of  the  radius  alone,  extension  should  be  made  from  the 
hand  (so  as  to  act  solely  on  the  radius),  whilst  the  elbow-joint  is 
grasped,  and  the  head  of  the  radius  pressed  into  position  by  the 
thumb  in  a  backward  or  forward  or  inward  direction,  according  to 
the  variety  of  the  dislocation.  In  the  other  dislocations  slight 
modifications  of  these  methods  are  required,  and  will  be  suggested 
by  a  knowledge  of  the  anatomy  of  the  joint,  a.nd  a  correct  diag- 
nosis of  the  nature  of  the  displacement. 

Afte7'-7reatment. — The  joint  should  be  placed  on  an  inside 
angular  splint  and  the  arm  in  a  sling,  and  evaporating  lotions  or 
ice  applied  to  prevent  inflammation.  Passive  movements  should 
be  cautiously  begun  about  ten  days  or  a  fortnight  after  the  injury. 

Complications. — i,  Fracture  of  {a)  the  coronoid  process  ;  (l?) 
the  olecranon;  (r)  the  neck  of  the  radius  ;  {d)  the  lower  end  of 
the  humerus  ;  and  {e)  the  condyles  of  the  humerus  ;  2,  separation 
of  the  lower  epiphysis  of  the  humerus  ;  3,  wound  of  the  joint ;  4, 
laceration  of  the  main  artery  ;  and  5,  injury  of  the  ulnar  or  other 
nerve. 

Treatment  of  compound  dislocation  of  the  elbow. — When  the 
patient  is  young,  the  wound  small,  the  laceration  and  bruising  of 
the  soft  parts  but  sHght,  and  the  bones  are  uninjured,  the  disloca- 
tion should  be  reduced,  and  the  case  treated  as  a  wound  of  the 
joint.  Otherwise  excision  of  the  joint,  or,  in  severe  cases,  ampu- 
tation, must  be  practiced. 

Dislocation  of  the  wrist  is  very  rare.  The  carpus  with  the 
hand  may  be  displaced  either  backwards  or  forwards.  In  the  dis- 
location backwards,  which  is  the  more  common  variety,  the  carpus 
forms  a  projection  on  the  dorsal  surface  of  the  wrist,  whilst  the 
ends  of  the  radius  and  ulna  project  on  the  palmar  surface.  It 
resembles  Colles'  fracture,  which  was  formerly  confused  with  it. 
In  the  dislocation  the  styloid  processes  of  the  radius  and  ulna  are 
on  the  normal  level,  and  are  nearer  the  knuckles  than  is  natural, 
and  there  is  no  crepitus.  Treatment. — Reduction  is  easily  affected 
by  making  extension  on  the  hand  and  pressing  upon  the  displaced 
bones.  The  forearm  and  hand  should  then  be  secured  to  a  splint, 
and  passive  movements  begun  early  to  prevent  stiffness. 

Dislocation  of  the  lower  end  of  the  radius  from  the  ulna 
may  be  produced  by  a  violent  twist  of  the  hand.  When  the 
twist  is  in  the  direction  of  pronation,  the  radius  is  displaced  for- 
wards ;  when  of  supination,  backwards.  The  former  is  the  more 
common.  The  hand  accompanies  the  radius,  and  the  styloid 
process  of  the  ulna  projects  prominently  in  the  opposite  direction, 
and  has  been  sometimes  forced  through  the  skin.     Treatment. — 


4i6 


INJURIES    OF    REGIONS. 


Fig.  163. 


Whilst  making  extension  from  the  hand,  manipulate  the  bone  into 
position  and  retain  it  there  by  a  compress  and  splint. 

Dislocations  of  the  carpal  and  imeiacarpal  bones  are  very 
rare.     Their  diagnosis  is  usually  obvious. 

The  pJia/aiigts  of  the  fingers  may  be  dislocated  backwards  or 
forwards.  Reduction  is  easily  effected  by  extension  and  manipu- 
lation. 

Dislocation  of  the  metacarpal  hone  of  the  thumb  from  the 
trapezium  may  occur  in  a  backward  or  forward  direction,  and  is 
easily  reduced  by  extension  or  pressure. 

Dislocation  of  the  first  phalanx  of  the  thumb  from  the  meta- 
carpal bone  is  of  more  importance.  The  phalanx  is  nearly 
always  displaced  backwards  ;  the  shortening  of  the  thumb  and 

the  projections  of  the  base  of  the 
phalanx  and  head  of  the  metacarpal 
bone  serve  for  its  diagnosis.  Reduc- 
tion is  often  very  difficult ;  this  is 
usually  ascribed  to  the  head  of  the 
metacarpal  bone  being  forced  between 
the  two  insertions  of  the  flexor  brevis 
pollicis  by  which  its  neck  is  tigthly 
embraced.  (Fig.  163.)  Sir  George 
Humphry,  however,  has  shown  that 
the  hindrance  to  reduction  depends 
upon  the  fact  that  the  sesamoid  bones 
and  the  ligaments  connecting  them 
are  carried  back  with  the  phalanx, 
and  being  held  there  by  the  flexor 
brevis  and  intervening  between  the 
metacarpal  bone  and  the  phalanx, 
prevent  the  articular  surfaces  of  the 
bones  being  brought  into  contact.  Treatment. — Press  the  meta- 
carpal bone  well  into  the  palm  of  the  hand  to  relax  the  flexor 
brevis  polhcis,  and  bend  back  the  first  phalanx  on  the  metacarpal 
bone  until  the  extremity  of  the  thumb  points  towards  the  wrist, 
thus  forcing  the  base  of  the  phalanx  wedge-wise  between  the  two 
insertions  of  the  short  flexor.  Next  flex  the  phalanx  while  an  as- 
sistant, by  placing  his  thumb  behind  its  base,  prevents  its  slipping 
back.  The  head  of  the  metacarpal  bone  will  now  prol)ably  slide 
into  its  place  between  the  two  insertions  of  the  flexor  brevis 
pollicis,  which  are  forced  apart  by  the  wedge-like  action  of  the 
base  of  the  i)halanx.  Reduction  may  sometimes  be  accomplished 
by  extension,  e.  g.,  by  the  clove-hitch,  or,  if  at  hand,  by  the 
Indian  puzzle-toy  or  the  American  forceps — a  method,  however, 
less  scientific  than  that  of  manipulation,  and  one  which  seldom 


Dislocation  of  the  thumb  back- 
wards at  the  mttacarpo-phalan- 
geal  joint.     lAfter  .Agnew.) 


FRACTURES   OF   THE   CLAVICLE.  417 

succeeds  if  the  other  fails.  These  means  not  proving  successful, 
it  is  usually  advised  that  the  insertion  of  the  flexor  brevis  pollicis 
should  be  subcutaneously  divided.  Sir  George  Humphry,  how- 
ever, recommends  an  incision  over  the  sesamoid  bones  and  the 
introduction  of  a  hook  to  hitch  the  sesamoid  bones  over  the  head 
of  the  metacarpal.  In  this  way,  he  says,  the  reduction  is  imme- 
diately effected.  As  a  last  resource,  the  joint  may  be  cut  down 
upon,  the  bands  resisting  reduction  divided  and  the  bone  replaced  ; 
or  the  joint  may  be  excised,  or  perhaps  better,  left  alone,  as  very 
fair  movement  will,  as  a  rule,  in  time  be  gained. 

Fractures  of  the  Upper  Extremity, 

Fractures  of  the  clavicle  are  divided  into  fractures  of — i,  the 
shaft;  2,  the  ac7'omial  end,.anA  3,  the  sternal  end. 

I.  The  Shaft  may  be  fractured  by  direct  violence,  or,  as  is  more 
commonly  the  case,  by  indirect  violence,  such  as  a  fall  upon  the 
arm  or  shoulder  ;  more  rarely  by  muscular  action.  Situatiojis. — 
When  the  result  of  indirect  violence  or  muscular  action,  the  bone 
is  generally  broken  near  its  centre — its  weakest  part.  When  due 
to  direct  violence,  the  bone  will  break  wherever  the  force  is  ap- 
plied. Nature  of  the  displacement. — The  inner  fragment,  although 
it  appears  raised  in  consequence  of  the  depression  of  the  outer,  is 
not  displaced,  being  held  in  position  by  the  sterno-mastoid  and 
the  rhomboid  ligament ;  the  outer  fragment  is  drawn  downwards, 
forwards  and  inwards  by  the  weight  of  the  arm  and  the  contrac- 
tion of  the  pectoral  muscles.  The  signs  in  an  adult  are  usually 
very  evident.  The  inner  fragment  projects  prominently  under 
the     skin ;      the     shoulder 

droops  forwards  and  down-  ^"^-  ^^4- 

wards ;  the  patient  usually 
supports  his  elbow  with  the 
sound  hand  whilst  he  in- 
clines his  head  to  the  frac- 
tured side  to  relax  the 
sternomastoid.  In  a  fat  "^  g^gj^^H  ^'■^'^'"'■^  °^  ^^^  clavicle.  (Holmes' 
child,    however,    especially 

when  the  fracture  is  of  the  greenstick  variety  (Fig.  164)  which  it 
often  is  in  children,  the  signs  are  less  evident ;  indeed  surgical 
aid  is  often  not  sought  until  the  mother's  attention  is  called  to  the 
part  by  the  presence  of  a  lump  formed  by  the  ensheathing  callus. 
Union  generally  occurs  in  about  three  weeks  in  children  and  five 
in  adults.  Treatment. — The  fracture  is  easily  reduced  by  draw- 
ing back  the  shoulders,  or  by  placing  the  patient  in  the  recumbent 
posture ;  but  it  is  very  difficult  to  maintain  the  fragments  in  ap- 


4i8 


INJURIES    OF    REGIONS. 


position.  Hence  the  numerous  bandages  and  apparatus  that  have 
been  from  time  to  time  employed.  Where  it  is  important  to 
avoid  deformity,  rest  on  the  back  for  a  fortnight  is  essential ; 
otherwise  the  patient  may  be  allowed  to  get  about  with  his  arm 
bandaged  to  the  side,  and  the  parts  kept  as  much  as  possible  in 
apposition  by  bandaging  or  strapping.  Of  the  many  plans  the 
following  may  be  tried  : 

I.  Sayre's  me/hod. — Take  three  pieces  of  adhesive  strapping 
about  three  inches  and  a  half  wide,  and  long  enough  to  surround 
the  arm  and  afterwards  the  body.  Stitch  one  piece,  with  the  ad- 
hesive surface  outside,  loosely  round  the  arm  on  the  injured  side 


Fig.  165. 


Fig.  167. 


Figs.  165,  166,  167. — Sayre's  method  of  treating  fractured  clavicle.     (After  Agnew.) 


at  the  insertion  of  the  deltoid  muscle.  Draw  the  arm  forcibly 
backwards  to  put  the  clavicular  portion  of  the  pectoralis  major  on 
the  stretch,  and  carry  the  strapping  across  the  back  and  round 
the  front  of  the  thorax  and  sew  the  end  to  the  part  which  crosses 
the  back  ( P'ig.  165),  Fix  one  end  of  the  second  strip  of  ])laster 
to  the  sound  shoulder  ;  carry  it  obliquely  across  the  back  beneath 
the  elbow  (which  should  be  pushed  forwards)  of  the  injured  side, 
a  slit  being  made  to  receive  the  olecranon  ;  bring  it  upwards  in 
front  of  the  chest,  and  fasten  it  to  its  other  end  over  the  sound 
shoulder  (Figs.  166  and  167).  A  third  strip  may  be  carried 
round  the  arm,  forearm  and  thorax  to  keep  the  others  in  place. 
The  first  stri])  acts  as  a  fulcrum  ;  whilst  the  second,  by  drawing 
the  elbow  forwards,  forces  the  ujjper  end  of  the  humerus,  with  the 


THE   SCAPULA.  419 

clavicle,  backwards,  and  at  the  same  time  keeps    the  shoulder 
raised. 

2.  Ellis^s  metJiod  consists  briefly  in  the  use  of  an  axillary 
crutch  supported  by  two  straps,  the  one  round  the  chest,  the 
other  passed  over  the  sound  shoulder.  The  chest  strap  also  en- 
circles the  arm  and  holds  it  firmly  to  the  side.  The  forearm  is 
further  supported  by  a  sling. 

3.  77^1?  axillary  pad  and  ba7}dage. — Many  surgeons  simply  place 
a  wedge-shaped  pad  with  the  base  upwards  in  the  axilla,  and  then 
bandage  the  arm  to  the  side  with  the  elbow  well  raised.  If  the 
pad  is  used,  care  should  be  taken  in  bandaging  lest  the  axillary 
vessels  or  nerves  are  compressed,  and  oedema,  pain,  or  even 
gangrene  of  the  arm  be  the  consequence. 

II.  Fraclure  of  the  acro7?iial  end  of  the  clavicle  may  occur 
either  at  or  external  to  the  insertion  of  the  coraco-clavicular  hga- 
ments.  In  the  former  situation  there  is  very  little  displacement, 
the  fragments  being  held  in  position  by  the  above-mentioned 
ligament!.  Pain,  crepitus,  and  possibly  a  sHght  gap,  will  serve  to 
distinguish  it.  When  external  to  the  ligaments,  the  outer  frag- 
ment is  drawn  down  nearly  at  a  right  angle  to  the  rest  of  the  bone, 
so  that  its  acromial  articulation  looks  inwards,  forwards  and 
slightly  downwards.  Ti-eatment. — An  axillary  pad  and  bandage, 
with  a  moulded  leather  shoulder-cap  to  protect  the  parts. 

III.  Fracture  of  the  sternal  end  is  too  rare  to  require  descrip- 
tion in  a  book  of  this  character. 

The  scapula. — The  fracture  may  extend  through  i,  the  body; 
2,  the  neck;  3,  the  acromion ;  4,  the  coracoid  process;  and  5, 
the  glenoid  cavity. 

1.  Fracture  of  the  body  is  nearly  always  caused  by  direct  vio- 
lence. It  may  be  star-shaped  or  transverse,  or  it  may  run  vertically 
or  obliquely  through  the  spine  ;  but  commonly  it  is  limited  to  the 
infraspinous  fossa,  and  frequently  the  angle  is  alone  broken  off. 
The  displacement  is  not  usually  very  marked,  as  the  fragments  are 
well  covered  with  muscles.  Signs. — On  fixing  the  angle  of  the 
scapula  with  one  hand,  and  raising  the  arm,  crepitus  and  pain 
may  be  elicited.  On  running  the  fingers  along  the  spine  and 
down  the  posterior  border,  some  irregularity  may  be  detected 
when  these  parts  are  involved,  and  on  grasping  the  bone  the  frag- 
ments may  be  felt  to  move  on  each  other.  Treatment. — Little 
can  be  done  beyond  confining  the  scapula  by  strapping  and  a 
bandage  to  the  chest,  and  restraining  the  motions  of  the  arm  by 
bandaging  it  to  the  side. 

2.  Fracture  of  the  neck. — By  this  is  understood  fracture  through 
the  surgical  neck,  /.  <?.,  internal  to  the  coracoid,  so  that  the  latter 
process  is  separated  with  the  glenoid  cavity  from  the  rest  of  the 


420 


INJURIES   OF    REGIONS. 


Fig.  I 


Fracture  of  the  neck  of  the  scap 
ula.   (Guy's  Hospital  Museum.) 


bone.  There  is  a  specimen  of  it  in  the  Hunterian  and  in  Guy's 
Hospital  Museum  (Fig.  i6S),  though  it  is  stated  by  some  not  to 
occur.  The  sigfis  which  have  been  ascribed  to  this  injury  re- 
semble those  of  dislocation  of  the  humerus  downwards.  The 
deformity,  however,  is  said  to  disappear  on  pressing  up  the 
elbow,  when  crepitus  can  be  elicited,  and  to  reappear  on  remov- 
ing the  pressure.  The  /rea/men/ recom- 
mended is  to  raise  the  elbow,  and 
maintain  the  parts  in  their  restored 
position  by  a  bandage. 

3.  Fracture  of  the  acromion  may 
occur  at  any  situation.  Cause. — Direct 
violence,  such  as  a  blow  or  fall  on  the 
shoulder.  Nature  of  the  displacement. — 
The  outer  fragment  is  drawn  down- 
wards by  the  deltoid,  leaving  a  gap  be- 
tween it  and  the  rest  of  the  bone. 
Symptoms.  —  Pain,  flattening  of  the 
shoulder,  presence  of  a  gap  on  drawing 
the  finger  along  the  spine,  acromion, 
and  clavicle ;  and  crepitus  on  raising 
the  arm  and  thus  bringing  the  fragments 
into  apposition.  Union. — When  near  the  tip  the  union  is  fibrous  ; 
when  near  the  base,  it  is  said  to  be  bony.  Treatment. — Raise  the 
elbow  so  as  to  relax  the  deltoid,  and  fix  the  arm  to  the  side  by  a 
sling  and  bandage,  protecting  the  parts  by  a  gutta-percha  cap 
moulded  to  the  shoulder.     Some  employ  an  axilla-pad. 

4.  Fracture  of  the  coracoid process  may  occur  either  near  the  tip 
or  near  the  root.  The  cause  is  usually  direct  violence,  such  as  a 
kick  or  fall  on  the  shoulder.  Nature  of  the  displacement. — When 
the  fracture  is  near  the  tip  the  distal  fragment  is  drawn  downwards 
by  the  biceps ;  when  near  the  root  it  is  held  in  position  by  the 
coraco-clavicular  ligaments,  and  but  little  displacement  occurs. 
Signs. — Bruising  and  pain  over  the  situation  of  the  coracoid.  On 
placing  the  finger  on  the  tip  of  the  coracoid  some  alteration  in  its 
relative  position  may  be  made  out,  and  crepitus  elicited  by  mov- 
ing the  arm.  Tieatment. — The  forearm  should  be  flexed  to  relax 
the  biceps ;  the  arm  and  forearm  bandaged  to  the  side  ;  and  a 
cap  of  gutta-percha  placed  over  the  shoulder. 

5.  I'racture  of  tlie  glenoid  cavity  is  rare.  At  times  it  occurs  in 
connection  with  dislocation  of  the  shoulder. 

The  humerus. — Fractures  of  the  humerus  are  divided  into  frac- 
tures of  I,  the  upper  end ;   2,  the  shaft,  and  3,  the  lower  end. 

1.  The  upper  end  of 'jhe  humerus — Varieties. — A.  Intracap- 
sular, or  fracture  of  the  anatomical  neck.     B.  Extracapsular,  or 


THE  UPPER  END  OF  THE  HUMERUS. 


421 


fracture   of    the   surgical    neck.     C.    Separation   of    the    upper 
epiphysis.     D.  Fracture  of  the  greater  tuberosity. 

A.  The  intracapsular  fracture  may  be  impacted  or  non-im- 
pacted. When  impacted  the  upper  fragment,  or  head,  is  com- 
monly driven  into  the  lower,  that  is,  between  the  tuberosities. 
Cause. — Generally  direct  violence,  as  a  blow  or  fall  on  the 
shoulder.  Signs. — Often  obscure.  There  may  be  pain,  swelling, 
impaired  movement  and  crepitus,  with  absence  of  signs  of  dislo- 
cation or  of  other  fracture  about  the  shoulder.  In  the  impacted 
variety  there  is  generally  some  prominence  of  the  acromion ;  loss 
of  rotundity  of  the  shoulder ;  slight  shortening  of  the  arm,  and 
inability  to  feel  the  whole  of  the  head  in  the  glenoid  cavity ; 
crepitus  is  not  as  a  rule  present,  though  it  m.ay  sometimes  be 
elicited  by  firmly  grasping  the  head  and  rotating  the  shaft. 
Method  of  union. — Fibrous  or  bony,  often  with  excess  of  callus 
and  impairment  of  movement  of  the  joint.  Treatment. — Apply  a 
leather  or  poroplastic  shield  to  the  shoulder  and  outer  side  of  the 
arm,  rectifying  any  displacement  inwards  by  a  pad  in  the  axilla. 
Bandage  the  arm  from  the  fingers  upwards  to  prevent  swelling, 
and  confine  it  to  the  side  of  the  chest  without  raising  the  elbow. 
When  the  fracture  is  impacted  do  not  disturb  the  fragments. 
Passive  movements  should  be  begun  early  (in  about  three  weeks). 

B.  The  extracapsular  fracture  is  the 
most  common, form  of  fracture  about  the 
shoulder.  It  may,  like  the  intracapsular 
variety,  be  impacted  or  non-impacted  ;  but 
when  impaction  occurs  it  is  the  lower  frag- 
ment that  is  driven  into  the  upper,  /.  <?., 
the  narrower  shaft  between  the  broader 
tuberosities.  Cause.  —  Generally  direct 
.violence.  Natuj-e  of  the  displacement. — 
The  upper  fragment  is  rotated  outwards  by 
the  three  muscles  inserted  into  the  greater 
tuberosity ;  the  lower  fragment  is  drawn 
upwards  by  the  deltoid  and  inwards  by  the 
three  muscles  inserted  into  the  bicipital 
ridges  (Fig.  169).  Signs. — Pain,  swelling 
and  impaired  movement ;  marked  shorten- 
ing of  the  arm  ;  projection  of  the  rough 
end  of  the  lower  fragment,  usually  below  the  coracoid  ;  and  in- 
creased mobility  of  the  arm  to  the  surgeon.  On  rotating  the  arm, 
the  head  remains  motionless  in  the  glenoid  cavity,  whilst  on  ex- 
tension crepitus  is  felt.  In  the  impacted  form  the  signs  are  very 
obscure,  and  principally  negative.  Thus,  there  may  be  deformity, 
sHght   shortening,    and   impaired    movement ;   but   there   is   no 


Extracapsular  fracture  of  the 
humerus.     (After  Gray.) 


42  2  INJURIES   OF    REGIONS. 

crepitus,  unless  unjustifiable  force  is  used.  Union  is  generally 
bony.  There  is  often  much  impairment  of  movement,  in  conse- 
quence of  inflammatory  thickening,  and  sometimes  paralysis  of 
the  deltoid,  from  the  involvement  of  the  circumflex  nerve  in  the 
callus.  Treatment. — Similar  to  the  intracapsular  form.  Place  a 
pad  in  the  axilla,  and  a  poroplastic  shield  over  the  shoulder  and 
outer  side  of  the  arm.  Support  the  hand  in  a  sling,  but  do  not 
raise  the  elbow,  in  order  that  the  weight  of  the  arm  may  act  as 
an  extending  force  to  overcome  the  upward  displacement. 

C.  Fracture  through  the  greater  tuberosity'  is  the  result  of  great 
violence,  and  is  very  rare.  N^ature  of  the  displacement. — The 
humerus  is  drawn  inwards  beneath  the  coracoid  process  by  the 
muscles  inserted  into  the  bicipital  ridges,  and  the  greater  tuber- 
osity backwards  by  the  three  muscles  inserted  into  it.  Signs. — 
The  shoulder  is  greatly  increased  in  breadth  :  a  vertical  gap  may, 
perhaps,  be  made  out  between  the  tuberosity  and  the  head  of  the 
bone ;  and  on  approximating  the  fragments  crepitus  can  be  felt. 
Treatment. — Endeavor  to  bring  the  fragments  into  contact  and  to 
keep  them  so  by  an  axillary  pad,  strapping  and  bandage ;  apply 
a  shield  over  the  shoulder,  and  confine  the  arm  to  the  side. 

D.  Separation  of  the  upper  epiphysis  can  only  occur  in  patients 
under  twenty-one  years  of  age.  Nature  of  the  displacenie?it. — The 
upper  fragment,  which  includes  the  tuberosities,  is  drawn  out- 
wards by  the  three  muscles  inserted  into  the  greater  tuberosity, 
and  the  lower  fragment  upwards  by  the  deltoid,  and  inwards  by 
the  three  muscles  inserted  into  the  bicipital  ridges.  The  signs 
are  similar  to  those  of  the  extracapsular  fracture,  save  that  the 
projecting  end  of  the  lower  fragment  is  smooth  and  rounded  in 
place  of  being  rough  and  uneven,  and  pseudo-crepitus,  instead  of 
bony  crepitus,  is  elicited  on  extension  and  rotation  of  the  arm. 
Method  of  union. — Usually  bony,  but  with  much  less  production 
of  callus,  and  consequently  less  impairment  of  movement  than 
in  other  fractures  of  the  upper  end.  Ti-eatment. — Like  that  of 
fracture  of  the  surgical  neck. 

2.  The  SHAfT  (JE  THE  HUMERUS  may  be  fractured  in  any  situa- 
tion, but  more  often  in  its  lower  than  in  its  upper  half.  Causes. 
— Direct  or  indirect  violence,  rarely  muscular  action.  Nature  of 
the  displacement. — When  the  line  of  fracture  is  transverse,  little 
displacement  occurs ;  but  when  it  is  oblique,  the  fragments  have 
a  tendency  to  glide  over  one  another,  owing  to  muscular  action, 
although  this  is  somewhat  counteracted  by  the  weight  of  the  arm. 
When  the  fracture  is  above  the  insertion  of  the  deltoid  the  upper 
fragment  is  drawn  inwards  by  the  muscles  inserted  into  the 
bicipital  ridges  ;  whilst  the  lower  fragment  is  drawn  upwards  by 
the  biceps  and  triceps,  and  outwards  by  the  deltoid.     When  be- 


THE  LOWER  END  OF  THE  HUMERUS. 


423 


Fig.  170. 


low  the  deltoid,  the  upper  fragment  is  drawn  outwards  by  that 
muscle  and  the  lower  fragment  upwards  and  inwards  by  the  biceps 
and  triceps.  Signs  usually  obvious,  viz.,  pain,  preternatural  mo- 
bility, and  generally  deformity  and  shortening ;  whilst  crepitus  is 
readily  obtained.  Method  of  union. — Generally  bony  ;  but  it  is 
one  of  the  most  common  situations  of  ununited  fracture.  Treat- 
ment— Place  the  arm  and  forearm  on  an  inside  rectangular  splint 
with  three  short  splints  to  the  humerus,  one  in  front,  one  behind, 
and  one  on  the  outer  side.  Or,  apply  four  short  splints  to  the 
humerus  and  support  the  forearm  by  a  sling,  leaving  the  elbow 
free,  so  that  the  weight  of  the  arm  may  act  as  an  extending  force. 
The  splints  should  be  worn  from  a  month  to  five  or  six  weeks. 
The  fingers  and  fore-arm  may  often  with  advantage  be  bandaged 
to  prevent  oedema. 

3.  The  LOWER  end  of  the  humerus. — Fractures  in  this  situa- 
tion may  be  divided  into  {a)  transvere  fracture  ;  {b)  separation  of 
the  epiphysis;  {c)  T-shaped  fracture;  {d)  fracture  of  the  con- 
dyles. Of  these,  the  transverse  when  above  the  condyles,  the 
separation  of  the  epiphysis,  and  the 
fracture  of  the  tip  of  the  internal  con- 
dyle, are  extra-capsular ;  the  others  in- 
volve the  joint.  Cause. — All  varieties 
are  generally  the  result  of  direct  violence, 
such  as  falls  upon  the  bent  elbow. 

(«:)  The  transverse  fracture  may  be 
above  or  below  the  condyles  ;  in  the 
former  case  it  is  extra-,  in  the  latter  in- 
tracapsular. Nature  of  the  displacement. 
— The  lower  fragment,  together  with  the 
bones  of  the  forearm,  are  drawn  back- 
wards and  upwards  behind  the  upper 
fragment  by  the  triceps,  whilst  the  lower 
end  of  the  upper  fragment  projects  in 
front  of  the  joint  (Fig.  170).  Signs. — 
The  forearm  is  shortened  and  generally 
bent  more  or  less  at  a  right  angle  to  the 
arm ;  the  olecranon  projects  posteriorly ;  and  the  lower  end  of 
the  upper  fragment  forms  a  prominence  in  front  of  the  joint.  The 
signs  are  similar  to  those  of  dislocation  of  the  radius  and  ulna 
backwards.  The  following  differences  presented  by  the  two 
injuries  should  serve  to  distinguish  them  ;  although  when  not 
seen  immediately  after  the  accident  the  condition  of  the  parts 
may  be  so  obscured  by  swelling  that  an  accurate  diagnosis  can- 
not be  made  till  the  inflammation  has  subsided.  Thus,  in  frac- 
ture— I,  the    deformity   is   readily    reduced,   but   reappears   on 


Fracture  of  the  lower  end  of  the 
humerus.     (After  Gray.) 


424  INJURIES   OF    REGIONS. 

removing  the  extending  force  ;  2,  crepitus  is  obtained  on  reduc- 
tion ;  3,  the  condyles  bear  normal  relations  to  the  olecranon  ;  4, 
the  distance  between  the  acromion  and  external  condyle  is  less 
than  on  the  sound  side  ;  5.  the  prominent  lower  end  of  the  upper 
fragments  projects  above  the  crease  at  the  front  of  the  elbow.  In 
dislocation,  on  the  other  hand — i,  the  deformity  does  not  reap- 
pear when  reduced  ;  2,  there  is  no  crepitus;  3,  the  distance  be- 
tween the  condyles  and  olecranon  is  increased  ;  4,  the  distance 
between  the  acromion  and  external  condyle  is  the  same  on  both 
sides,  and  5,  the  prominent  lower  end  of  the  humerus  projects 
beloiv  the  crease  at  the  front  of  the  elbow. 

{b)  Separation  of  the  epiphysis. — The  signs  are  similar  to  the 
above,  but  the  patient  is  under  twenty-one  years  of  age. 

{c)  T-shaped  fracture. — In  this  there  is  a  transverse  fracture 
above  the  condyles,  combined  with  a  vertical  or  oblique  fracture 
extending  between  the  condyles,  into  the  joint.  Signs. — Similar 
to  the  transverse  fracture,  except  that  the  condyles  move  on  one 
another  as  well  as  on  the  shaft,  and  the  distance  between  them  is 
increased.  These  signs,  however,  are  often  obscured  by  great 
effusion  in  and  around  the  joint. 

iyd)  Fracture  of  the  condyles. — The  projecting  internal  condyle 
may  be  broken  off  without  implicating  the  joint;  or  the  fracture 
may  extend  obliquely  through  either  condyle  and  the  contiguous 
articular'  surface  into  the  point.  Cause. — Generally  direct 
violence.  Signs. — Mobility  and  crepitus  on  grasping  the  con- 
dyles, and  on  flexing  and  extending  the  forearm  when  the  internal 
condyle  is  fractured,  and  on  pronating  and  supinating  the  hand 
when  the  external  condyle  is  fractured. 

Method  of  u?iio?i. — The  extracapsular  varieties  unite  by  bone, 
the  intracapsular  by  fibrous  tissue.  In  the  T-shaped  fracture  the 
transverse  portion  unites  by  bone ;  the  vertical  or  oblique,  /.  e., 
the  portion  inside  the  joint,  by  fibrous  tissue. 

Treatment. — If  there  is  much  swelling,  and  you  cannot  be  quite 
sure  that  there  is  no  dislocation,  place  the  limb  on  a  pillow,  or 
better,  on  a  Stromeyer's  cushion,  and  apply  cold  in  the  form  of 
lead  lotion  or  ice,  till  the  swelling  has  subsided.  Subsequently 
reduce  the  fracture,  and  i)lace  the  arm  and  forearm  on  an  angular 
splint  or  on  a  bent  anterior  splint,  or  in  Bavarian  plaster,  moulded 
leather,  or  poroplastic  felt  splints.  Passive  movements  of  the 
elbow  should  be  begun  early  whenever  the  fracture  involves  the 
joint,  but  when  it  is  transverse  above  the  joint  they  should  be  de- 
layed for  a  month,  since  there  is  then  no  danger  of  a  stiff  joint, 
but  a  risk  of  the  passive  movements  at  the  seat  of  fracture  leading 
to  a  false  joint.  Where  the  internal  condyle  only  is  chipped  off, 
the  angular  splint  should  be  placed  on  the  outer  side  of  the  arm. 
In  the  other  forms  it  is  usually  applied  to  the  inner  side. 


THE    RADIUS.  425 

The  radius  and  ulna.  Caiise. — Generally  direct  violence, 
when  each  bone  breaks  in  the  same  transverse  Hne  at  the  spot 
where  the  force  is  applied ;  occasionally  indirect  violence,  as  a 
fall  on  the  hand,  when  each  bone  generally  breaks  at  its  weakest 
part — the  radius  in  its  upper  third,  the  ulna  in  its  lower  third. 
Nature  of  the  displacement. — The  upper  fragment  of  the  radius  is 
drawn  by  the  pronator  teres  towards  the  upper  fragment  of  the 
ulna,  which  in  consequence  of  its  hinge-shaped  articulation  with 
the  humerus  is  not  displaced.  The  lower  fragments  are  drawn 
towards  each  other  by  the  pronator  quadratus.  Signs. — Obvious 
deformity,  crepitus,  etc.  Treatment. — Flex  the  elbow  to  relax 
the  muscles  j  reduce  the  fracture,  and  place  the  forearm  in  well- 
padded  splints  with  the  thumb  uppermost.  In  this  position  the 
bones  are  midway  between  pronation  and  supination,  and  parallel 
to  one  another.  There  is,  consequently,  a  good  interval  between 
them,  and  the  danger  of  the  radius  becoming  united  by  callus  to 
the  ulna,  as  in  Fig.  54,  is  avoided.  During  pronation  the  radius 
crosses  the  ulna.  Were  the  fracture  set  with  the  bones  thus  in 
contact,  the  risk  of  their  uniting  would  be  great.  The  splints 
should  reach  from  above  the  elbow  to  below  the  wrist,  and  should 
be  broader  than  the  forearm,  so  that  the  bones  may  not  be 
pressed  together  by  the  bandage.  If  this  point  is  attended  to,  in- 
terosseous pads  are  not  necessary.  The  patient  should  be  seen 
within  twenty-four  hours,  as  swelhng  may  occur  and  the  bandages 
require  loosening.  The  splints  must  be  worn  for  about  a  month, 
and  passive  movements  of  the  fingers  practiced  early  to  prevent 
stiffening. 

Greenstick  fracture  of  the  radius  and  ulna  is  common  in  chil- 
dren. 

The  Radius. — Fractures  of  the  radius  may  involve,  i,  the  neck  ; 
2,  the  shaft,  and,  ^,  the  lower  end.  (CoUes'  fracture). 

1.  The  neck  of  the  radius  is  occasionally  fractured.  It  may  be 
known  by  crepitus,  and  by  the  absence  of  movement  of  the  head 
when  the  hand  is  pronated  and  supinated.  Treatment. — Flex  the 
forearm,  and  place  the  limb  on  an  angular  splint. 

2.  The  shaft  of  the  radius  may  be  fractured  by  direct  or  indi- 
rect violence.  Both  fragments  are  drawn  towards  the  ulna,  the 
upper  by  the  pronator  teies,  the  lower  by  the  pronator  quadratus. 
(Fig.  171.)    Treatment. — Similar  to  that  of  fracture  of  both  bones. 

3.  Fracture  of  the  lower  end  of  the  radius  (  Colics''  fracture^. — 
The  line  of  fracture  generally  runs  transversely  about  three-quar- 
ters of  an  inch  above  the  articular  surface  of  the  bone.  Cause. — 
Falls  on  the  palm  of  the  hand.  It  is  more  frequent  in  the  old 
than  in  the  young;  and  is  especially  common  in  elderly  women. 
Nature  of  the  displacement. — Sometimes  there  may  be  no  displace- 

18* 


426 


INJURIES   OF   REGIONS. 


ment,  but  generally  the  lower  fragment  with  the  hand  is  so  dis- 
placed that  the  articular  surface  looks  dov;nwards,  and  slightly 
backwards  and  outwards,  instead  of  downwards,  forwards  and  in- 
wards. This,  according  to  Mr.  R.  W.  Smith,  is  due  to  the  action 
of  the  supinator  longus,  the  extensors  of  the  thumb  and  the 
radial  extensors  of  the  carpus.  By  others  it  is  believed  to  be 
due  to  the  impaction  of  the  upper  fragment  into  the  lower, 
a  condition  frequently  met  with  in  specimens  preserved  in 
museums.  Occasionally  the  lower  fragment  is  displaced  forwards 
in  consequence  of  falls  on  the  back  of  the  hand.  Comminu- 
tion of  the  lower  fragment  with  involvement  of  the  wrist  joint 
frequently  occurs.  Signs. — Very  characteristic.  On  the  back  of 
the  wrist,  just  above  the  joint,  there  is  a  prominence  caused  by 
the  backwardly  displaced  lower  fragment,  and  above  this  a  slight 
depression ;  whilst  on  the  palmar  surface  there  is  a  prominence 
caused  by  the  lower  end  of  the  upper  fragment,  corresponding  to 
the  dorsal  depression,  and  below  this  a  depression  corresponding 


Fig.  171. 


Fig.  172. 


Fracture  of  the  radius.     (After  Gray.) 


Colles'  Fracture.     (St.  Bartholomew's 
Hospital  Museum.) 


to  the  dorsal  prominence.  Pronation  and  supination  are  lost,  the 
hand  is  deflected  to  the  radial  side,  and  the  lower  end  of  the  ulna 
is  prominent.  The  deformity  is.  well  seen  in  Fig.  172.  These  signs 
are  similar  to  those  of  dislocation  of  the  carpus  backwards.  The 
following  points  will  serve  to  distinguish  the  two  injuries  :  In 
fracture,  i,  the  styloid  process  of  the  radius  is  on  a  higher  plane 
than  that  of  the  ulna  ;  2,  the  distance  from  the  internal  condyle 
to  the  tip  of  the  styloid  process  of  the  radius  is  less  than  on  the 
sound  side;  3,  there  is  crepitus;  4,  the  deformity,  when  it  can 
be  reduced,  has  a  tendency  to  return  if  the  extending  force  is  re- 
laxed ;  and,  5,  it  is  very  common  in  the  old,  and  occurs  from 
slight  causes.  In  disioca/ion,  on  the  other  hand,  i,  the  styloid 
process  of  the  radius  is  on  a  lower  plane  than  that  of  the  ulna  ; 
2,  the  distance  from  the  intern.il  condyle  to  the  tip  of  the  styloid 
process  of  the  radius  is  the  same  as  on  the  sound  side  ;  3,  there  is 
no  crepitus;  4,  the  deformity  when  reduced  has  no  tendency  to 
return  when  the  extending  force  is  relaxed  ;  and,  5,  it  i.;  usually 


THE   ULNA. 


427 


the  result  of  great  violence,  and  more  frequently  occurs  in  the 
young  than  in  the  old.  Treatment. — After  reducing  the  fracture 
as  thoroughly  as  possible,  apply  two  ordinary  forearm  splints,  tak- 
ing care  that  the  anterior  one  does  not  reach  beyond  the  heads 
of  the  metacarpal  bones,  and  place  a  pad  beneath  the  wrist  to  re- 
store the  lost  concavity  of  the  front  of  the  radius.  Practice  pass- 
ive movements  from  the  third  day,  as  in  this  form  of  fracture  the 
tendons,  where  they  cross  the  back  of  the  radius,  the  seat  of 
fracture,  are  apt  to  become  adherent  to  their  grooves.  This  is 
the  almost  invariable  method  of  treating  Colles'  fracture  at  St. 
Bartholomew's  Hospital,  and  is  attended  with  excellent  results. 

Fig.  173. 


Gordon's  splint  for  Colles'  fracture.     (Gordon's  Fractures.) 


If  preferred,  Gordon's  (Fig.  173),  Carr's,  Hawkins'  or  Bond's 
splints  may  be  used.  The  pistol-shaped  splint  introduced  by 
Nclaton,  and  justly  condemned  by  Sir  James  Paget  as  so  frequent 
a  cause  of  stiff  wrist  and  fingers,  should  on  no  account  be  used. 
Remove  the  sphnts  in  about  four  weeks,  and  employ  shampoo- 
ing, fiiction  with  stimulating  liniments,  etc.,  till  any  stiffness  of  the 
joint  or  fingers  that  remains  has  disappeared. 

Separation  of  the  loiver  epiphysis  may  occur  in  young  subjects, 
and  resembles  Colles'  fracture. 

The  ulna. — Fractures  of  the  ulna  may  be  divided  into  fracture 
of — I,  the  olecranon;  2,  the  coronoid  process,  and  3,  the  shaft. 

I.  The  olecranon  may  be  fractured  in  a  transverse  or  oblique 
direction.  The  elbow-joint  is  always  involved,  except  when  the 
fracture  is  through  the  tip  of  the  process  only.  Cause. — Direct 
violence,  as  a  fall  on  the  point  of  the  elbow,  or  violent  action  of 
the  triceps  muscle.  Naticre  of  the  displacement  (Fig.  174). — The 
detached  fragment  is  usually  widely  separated  from  the  rest  of  the 
bone  by  the  triceps  ;  but  when  the  periosteum  and  tendinous  ex- 
pansion of  the  triceps  covering  the  olecranon  is  not  torn,  and  the 


428 


INJURIES   OF   REGIONS. 


Fracture  of  the  olecranon.     (Liston's  Surgery.) 


fracture  is  very  oblique,  little  or  no  displacement  occurs.  Sig/is. 
— Swelling  from  eftusion  of  blood,  and  later  of  serum,  into  the 
joint ;  inability  of  the  patient  as  a  rule  to  extend  his  arm  ;  and 
generally,  the  presence  of  a  gap  between  the  fragments.     Method 

of     union. — Usually 
F"=-  ^74-  fibrous ;    but    when 

the  separation  of  the 
fragments  is  slight, 
it  may  be  bony. 
Treatment.  —  Place 
the  elbow  in  a  posi- 
tion of  slight  flexion 
on  a  jointed  splint, 
and  apply  evaporating  lotions  till  the  swelling  has  subsided.  An 
attempt  may  be  made  to  bring  down  the  detached  fragments  by 
strapping  and  a  bandage.  Passive  movements  should  be  begun 
early  to  prevent  ankylosis  (seventh  day,  Hamilton).  Many  ad- 
vise that  the  arm  should  be  put  up  in  full  extension  ;  but  this  is 
objectionable,  as  it  causes  the  olecranon  to  form  an  angle  with  the 
shaft.  Mr.  Heath  on  the  other  hand  strongly  recommends  flex- 
ion of  the  arm  to  a  right  angle. 

2.  The  coronoid process  of  the  ulna,  except  in  dislocation  of  the 
ulna  and  radius  backwards,  is  rarely  fractured.  It  is  said  at  times 
to  occur  from  a  violent  contraction  of  the  brachialis  anticus 
muscle.  Signs. — When  fracture  of  the  coronoid  is  present  in  dis- 
locadon  of  the  radius  and  ulna  backwards,  the  dislocation  is 
readily  reduced,  but  immediately  returns  on  relaxing  the  extend- 
ing force.  AVhen  fracture  of  the  coronoid  is  not  present,  the 
dislocation  is  more  difficult  to  reduce  ;  but  when  once  reduced, 
has  no  tendency  to  recur.  Treatment. — After  reducing  the  dis- 
location, place  the  arm  in  a  flexed  position  on  an  inside  angular 
splint.     Employ  passive  movements  early. 

3.  The  shaft  of  the  nlna  is  occasionally  fractured  without  impli- 
cation of  the  radius.  Cause. — Direct  violence.  Nature  of  the  dis- 
placement.— The  upper  fragment  is  not  displaced,  being  held  in 
position  by  its  hinge-shaped  articulation  with  the  humerus.  The 
lower  fragment  is  drawn  towards  the  radius  by  the  pronator 
quadratus.  Signs. — It  is  readily  detected  by  running  the  finger 
along  the  prominent  posterior  border  of  the  bone,  when  a  gap  or 
irregularity  is  felt,  and  by  crepitus  on  movement.  Treatment. — 
Similar  to  that  of  fracture  of  the  radius. 

The  carpus,  metacarpus  and  phalanges. — Fractures  of  these 
bones  require  no  special  mention.  They  may  be  diagnosed  by 
the  deformity  and  crepitus.  Rest  for  a  few  weeks  on  a  splint, 
followed  by  passive  movements  to  prevent  stiffness,  is  all  that  is 
generally  necessary. 


DISLOCATION   OF   THE    HIP.  429 

INJURIES  OF  THE  LOWER  EXTREMITY. 

Bruises  or  contusions,  burns,  scalds,  and  frost-bites  of  the 
lower  extremity  call  for  no  special  mention  beyond  that  bruises 
about  the  hip  and  ankle  may  be  mistaken  for  fracture,  and  that  a 
contusion  of  the  limb  may  be  so  severe  at  times  as  to  terminate  in 
gangrene. 

Sprains  of  the  ankle  and  knee  are  very  common.  Pain,  inabil- 
ity to  bear  any  weight  on  the  limb,  effusion  into  the  joint  or  the 
sheaths  of  the  surrounding  tendons,  and  later,  eccyhmosis  of  the 
skin,  are  the  usual  signs.  A  sprain  of  the  ankle,  when  there  is 
much  swelling,  is  often  difficult,  and  sometimes  impossible,  to 
diagnose  from  a  fracture,  and  should  then  be  treated  as  such. 
For  an  ordinary  sprain  absolute  rest  should  be  enjoined,  and  cold 
or  evaporating  lotions  or  a  wet  bandage  should  be  applied.  When 
the  swelhng  has  subsided,  the  part  may  be  put  in  a  plaster-of- 
Paris  bandage  or  in  a  poroplastic  spHnt  for  some  weeks,  and  then 
shampooing  and  passive  movements  employed  if  any  stiffness  be 
left. 

Rupture  of  muscles  and  tendons,  either  as  the  result  of  ex- 
ternal violence  or  of  sudden  and  spasmodic  contraction  of  the 
muscle,  is  not  infrequent  in  the  lower  limbs.  Here,  only  rupture 
of  the  plantaris  or  Achilles  tendon  requires  special  notice.  It 
usually  happens  in  men  beyond  the  middle  period  of  life  with- 
out any  evident  cause.  It  is  attended  with  a  distinct  snap,  and 
a  feeling  as  if  the  part  had  been  struck,  followed  by  pain,  and 
sometimes  by  ecchymosis,  and  by  inabihty  to  raise  the  heel. 
Treatment. — A  plaster-of-Paris  bandage  should  be  applied  with 
the  foot  in  the  extended  position  to  approximate  the  ends  of  the 
ruptured  tendon.  If  a  heel  is  made  to  the  plaster  case,  the 
patient  need  not  lay  up.  The  plaster  case  should  be  worn  for  two 
or  three  weeks. 

Dislocations  of  the  Lower  Extremity. 

Dislocation  of  the  hip. — This  injury  is  much  less  common 
than  dislocation  of  the  shoulder,  a  fact  readily  explained  by  the 
strength  of  the  capsular  hgament,  the  depth  of  the  acetabulum, 
and  the  powerful  muscles  by  which  the  joint  is  surrounded.  It 
occurs,  however,  more  frequently  than  might  be  expected,  owing 
to  the  powerful  leverage  which,  from  the  great  strength  of  the 
femur  and  length  of  the  leg,  is  brought  to  bear  upon  the  joint  in 
falls  upon  the  knee  and  foot  with  the  limb  extended  and  abducted. 
Dislocation,  therefore,  as  might  be  inferred,  is  more  common  in 
the  young  and  strong  ;  fracture  of  the  neck  of  the  femur  in  the 
old  and  feeble.     Cause. — Dislocation  of  the  hip,  whatever  form  it 


430  INJURIES   OF   REGIONS. 

may  take,  generally  occurs  when  the  limb  is  abducted.  In  this 
position  the  head  of  the  bone  presses  upon  the  inner  and  lower 
part  of  the  capsule,  its  weakest  part,  and  if  any  sudden  or  great 
force  is  now  applied  to  the  other  end  of  the  lever,  the  head  of  the 
bone  may  be  forced  through  the  capsule  at  this  spot  into  the  ob- 
turator foramen.  Here  it  may  remain,  or  if  at  the  time  of  the  ac- 
cident the  limb  is  flexed  and  rotated  inwards  as  well  as  abducted, 
it  may  be  carried  round  the  outer  margin  of  the  acetabulum  on 
to  the  dorsum  ilii ;  or  if  the  hmb  is  extended  and  rotated  out- 
wards as  well  as  abducted,  round  the  inner  margin  of  the  pubes. 
In  rare  instances,  it  would  appear  to  occur  during  forced  adduc- 
tion of  the  limb,  the  head  of  the  bone  being  then  driven  directly 
backwards  on  to  the  dorsum  ilii.  In  such  a  case,  however,  the 
rim  ot  the  acetabulum  is  generally,  though  not  always,  splintered 
off  at  the  same  time. 

The  Y,  or  ilio-femoral  ligament  plays  so  important  a  part  in  dis- 
location of  the  hip  that  its  attachments  should  he  briefly  consid- 
ered before  studying  the  varieties  of  this  dislocation.  It  consists 
of  a  thickening  of  the  front  of  the  capsular  ligament,  and  is  at- 
tached above  to  the  anterior  inferior  spine  of  the  ilium,  and  then 
divides  into  two  branches  like  the  letter  Y  inverted.  The  outer 
branch  is  inserted  into  the  upper  part  of  the  anterior  trochanteric 
ridge ;  the  inner  branch  into  the  lower  part  of  that  ridge.  It  is 
exceedingly  strong,  and  will  bear  a  breaking  strain  of  from  250  to 
750  pounds.  Both  branches  limit  extension  ;  the  outer  branch 
rotation  outwards  as  well.  The  whole  ligament  therefore  is  tense 
during  extension  and  outward  rotation  of  the  limb ;  relaxed  dur- 
ing flexion  and  rotation  inwards. 

Varieties. — Dislocations  of  the  hip  are  divided  by  Bigelow  into 
the  regula?;  in  which  one  or  both  branches  of  the  Y  ligament  are 
intact,  and  the  tr>egi//ar,  in  which  both  branches  are  ruptured. 
In  the  former  the  signs  are  constant,  as  the  untorn  branch  of  the 
Y  ligament  compels  the  bone  to  take  a  certain  definite  position. 
In  the  irregular  the  signs  vary,  as  both  branches  of  the  Y  being 
ruptured,  the  control  which  it  exercises  over  the  position  of  the 
bone  is  lost.  Our  attention  here  will  only  be  directed  to  the 
regular  dislocations.  Of  these  13igelow  describes  seven,  the  first 
four  of  which  are  commonly  known  as  the  classical  dislocations  of 
Sir  Asiley  Cooper. 


DISLOCATION   OF   THE   HIP. — VARIETIES. 


43^ 


cooper's    CLASSIFICATION.       BIGELOW's    CLASSIFICATION. 

A.  Regular.     One  or  both 
branches  of^  entire. 

Dislocation  on  to  the  dor-  )  t->        i 

.,..  h  =  I-  Dorsal 

sum  ini  j 

Dislocation  into  the  sci-  |  ^  2.  Dorsal    below    the 

atic  notch  j  tendon 

Dislocation  into  the  ob-  |  ^  3.  Thyroid  and  down-   \ 


turator  foramen 
Dislocation     on    to 
pubes 


] 
the  1^4. 

5- 
6. 


wards 
Pubic     and 

spinous 
Anterior  oblique 


sub- 


Both 
branches 

of  Y 
entire. 


1 


Supraspinous  j       Outer 

\-  branch  of 

Everted  dorsal  Y 

'    ruptured. 

B.  Irregular.     Both  branches 
ofi  ruptured. 


1.  Dislocation  on  to  the  dorsum  ilii  {the  dorsal  of  Bige low). — 
This  is  the  most  common  form  of  dislocation  of  the  hip.  The 
head  of  the  bone  is  thrown  upwards  and  backwards  on  to  the 
dorsum  of  the  ilium,  the  articular  surface  of  the  head  looking 
backwards,  and  the  great  trochanter  forwards.  The  capsular 
ligament  is  generally  ruptured  at  its  lower  and  inner  part,  some- 
times posteriorly,  and  the  lound  ligament  is  usually  torn.  The  Y 
ligament  is  uninjured,  the  external  branch  preventing  eversion. 
The  glutei  muscles  are  raised  from  the  ilium  by  the  head  of  the 
bone,  which  is  always  situated  above  the  tendon  of  the  obturator 
internus.  The  other  external  rotators  have  been  found  variously 
lacerated  or  torn  from  their  attachments.  Signs  (Fig.  175). — 
The  limb  is  slightly  flexed,  adducted,  rotated  inwards,  and  short- 
ened, so  that  the  lower  end  of  the  femur  crosses  the  lower  third 
of  the  opposite  thigh,  and  the  great  toe  rests  on  the  instep  of  the 
opposite  foot.  The  head  of  the  bone,  at  least  in  thin  subjects, 
can  be  felt  in  its  abnormal  situation  on  rotating  the  limb.  The 
great  trochanter  is  above  a  line  drawn  from  the  anterior  superior 
iliac  spine  to  the  most  prominent  part  of  the  tuberosity  of  the 
ischium  {Nelaton's  line)  (Fig-  i??)  J  s^id  the  distance  from  the 
top  of  the  great  trochanter  to  a  line  drawn  horizontally  round  the 
pelvis  on  a  level  with  the  anterior  superior  iliac  spines  {Bryant's 
line)  is  less  on  the  injured  than  on  the  sound  side. 

2.  Dislocation  into  the  sciatic  notch  {the  dorsal beloiu  the  tendon 


432 


INJURIES    OF    REGIOKS. 


of  Bige/otu). — The  head  of  the  bone  escapes  below  the  tendon  of 
the  obturator  internus,  and  then  ascends  behind  it  on  to  the  sur- 
face of  the  ihum  just  in  front  of  the  sciatic  notch,  or  on  the  pyri- 
forniis  as  it  emerges  from  the  notch.  The  head  looks  backwards 
and  the  great  trochanter  for\vards,  eversion  being  prevented  by  the 
outer  branch  of  the  Y  ligament.     The  tendon  of  the  obturator 


Fig.  175. 


Fic.  176. 


Dislocation  on  dorsum  ilii. 


Dislocation  into  sciatic  notch. 
(Cooper's  Dislocations.) 


internus  winds  over  the  neck  of  the  femur,  and  is  therefore  the 
great  obstacle  to  reduction.  The  capsule  is  generally  torn  below, 
the  round  ligament  ruptured,  the  gluteus  maximus  raised  by  the 
head  of  the  bone,  and  one  or  more  of  the  external  rotators  are 
usually  torn.  The  Si^c^iis  (  Kig.  176)  are  very  similar  to  those  of  the 
former  variety  ;  but  the  flexion,  adduction,  and  rotation  inwards 
are  less  pronounced.  The  lower  end  of  the  femur  crosses  the 
opposite  knee,  and  the  great  toe  rests  on  that  of  the  opposite  foot. 
Shortening  with  the  limb  extended  is  much  less  than  in  the  former 


DISLOCATION   OF   THE    HlP. — VARIETIES. 


433 


Fig.  177. 


A — B,  Nelaton's  line. 


variety;  but  with  the  limb  flexed  it  is  much  greater.  This  is 
shown  in  the  accompanying  diagram  (Fig.  178),  and  depends  upon 
the  fact  that  in  the  dislocation  on  to  the  dorsum  ilii  the  head  of  the 

bone  in  extension  lies  above 
the  acetabulum,  and  when 
flexed  at  a  right  angle  to  the 
body  on  the  same  level  as  the 
acetabulum  ;  whereas  in  the 
sciatic  dislocation  the  head  of 
the  bone  in  extension  is  al- 
most on  the  same  level  as  the 
acetabulum,  but  when  flexed 
at  a  right  angle  to  the  body 
Hes  considerably  behind  the 
acetabulum, 

3.  Dislocatio7i  into  the  ob- 
turator foramen  {the  thyroid 
and  doivnwards  of  Bigelow) . 
— The  head  is  displaced  down- 
wards on  to  the  obturator  ex- 
ternus,  where  it  lies  suspended 
by  the  Y  ligament,  and  may 
remain  either  just  below  the 
acetabulum,  or  be  carried  sHghtly  inwards  towards  the  perineum, 
or  outwards  towards  the  tuberosity  of  the  ischium.     The  head  of 

the  bone  generally 
looks  slightly  inwards, 
and  the  trochanter 
outwards.  The  cap- 
sule and  round  liga- 
ment are  ruptured, 
the  former  at  its  lower 
and  inner  part.  The 
glutei,  pyriformis, 
psoas  and  iliacus,  ob- 
turator externus,  pec- 
tineus,  and  the  ad- 
ductor brevis  are 
stretched  or  some- 
times torn.  Signs 
(Fig.  179). — In  the 
more  common  form, 
viz.,  that  in  which  the 
head  is  displaced 
downwards  and  a  little  inwards,  the  limb  is  a.^'p^Lrcntly  /engthened, 
19 


Sci.ntic  dislocation  of  the  left  hip.  n,  shows  slight  shorten- 
ing in  extended  position  of  limb;  6,  shows  marked  short- 
ening in  fle.xed  position.     (After  Dawson,  ot  Ohio.) 


434 


INJURIES    OF    REGIONS. 


due  to  the  lowering  of  the  pelvis  on  that  side,  but  is  really  short- 
ened about  half  an  inch  or  so.  It  is  also  abducted  and  slightly 
flexed,  whilst  the  body  is  bent  forwards  to  relax  the  psoas  and 
iliacus,  and  as  there  is  usually  some  external  rotation,  the  toes 
point  slightly  outwards.  The  nearer  the  head  of  the  bone  ap- 
proaches the  perineum  the  more  plainly  can  it  be  felt,  and  the 


Fig.  179. 


Fig.  180. 


Uislocalion  into  obturator  foramen. 


(Cooper's  Dislocations.) 


Dislocation  on  the  pubes. 


more  eversion  and  abduction  will  there  be  ;  conversely,  the  nearer 
it  apj)roa(hes  the  tuberosity  of  the  ischium,  the  greater  its  inver- 
sion and  adduction  ;  whilst  when  it  is  disi)lacetl  directly  down- 
wards there  will  be  neither  eversion  nor  inver.^ion,  adduction  nor 
abduction,  but  marked  flexion. 

4.  Dislocation  on  to  tlie  pubes  {tlic  pubic  and  subspinous  of  Bif:;e- 
iow). — 'J'he  head  of  the  l)one  is  thrown  forwards  and  rests  below 
Poupart's  ligament,  cither  upon  the  ramus  of  the  pubes  {pubic)  or 


DISLOCATION   OF   THE    HIP. — VARIETIES.  435 

upon  the  pectineal  eminence  just  in  front  of  the  anterior  inferior 
spine  {subspinous).  The  head  looks  forwards  and  the  trochanter 
backwards.  The  capsule  is  generally  torn  below,  and  the  round 
ligament  ruptured.  The  Y  ligament  is  entire  and  produces  the 
eversion  of  the  limb  characteristic  of  this  variety.  The  psoas  and 
iliacus,  with  the  anterior  crural  nerve  between  them,  are  generally 
stretched  tightly  over  the  head  of  the  bone.  The  femoral  vessels 
are  displaced  to  its  inner  side,  ^^igiis  (Fig.  t8o). — The  limb  is 
slightly  shortened,  flexed,  abducted,  and  rotated  outwards  ;  and 
the  head  of  the  bone  can  be  plainly  felt  in  its  new  situation. 
There  is  flattening  over  the  hip-joint. 

The  anterior  oblique,  st/praspinous,  and  everted  dorsal,  the  three 
remaining  regular  dislocations  of  Bigelow,  are  too  rare  to  be 
described  here.  They  can  readily  be  produced,  however,  on  the 
dead  body.  Thus  the  ordinary  dorsal  dislocation  can  be  con- 
verted into  the  anterior  oblique  by  carrying  the  leg  across  the 
symphysis,  forcibly  everting  the  thigh  and  bringing  it  down  across 
the  lower  third  of  the  opposite  thigh,  in  which  position  it  becomes 
firmly  locked.  If  now  the  thigh  is  forced  into  the  perpendicular 
position,  the  outer  branch  of  the  Y  ligament  will  be  ruptured  and 
the  supra-spinous  variety  produced.  This  variety  in  its  turn  can 
be  converted  into  the  everted  dorsal  by  circumducting  the  ex- 
tended limb  inwards  and  then  e\erting  it. 

Treatment. — Pv.eduction  may  be  eftected  by  :  i,  manipulation  ; 
2,  traction  with  the  limb  in  the  flexed  position  ;  3,  traction  with 
the  limb  in  the  extended  position.  Of  these  methods  the  first  and 
the  second  are  by  far  the  most  scientific,  and  when  their  principles 
are  thoroughly  understood  and  they  are  rightly  applied,  they  are 
the  most  successful.  Recent  dislocations  should  always  be  re- 
duced by  the  first  or  second  method,  aided  if  need  be  by  an 
anaesthetic  ;  and  these  methods  will  also  often  succeed  in  reducing 
cases  of  long  standing  after  traction  in  the  extended  position, 
even  with  the  pulleys,  has  failed.  In  long-standing  cases,  should 
the  above-mentioned  methods  fail,  reduction  may  under  some 
circumstances  be  attempted  by  4,  open  incision. 

I.  Reduction  by  manipulation  consists  in  relaxing  the  Y  ligament, 
the  chief  obstacle  to  reduction,  and  then  by  means  of  various 
movements  of  rotation,  circumduction  and  extension  apphcable 
to  each  particular  variety  of  dislocation,  in  making  the  head  of 
the  bone  retrace  its  steps  round  the  margin  of  the  acetabulum,  and 
finally  re-enter  the  acetabulum  through  the  hole  in  the  capsule 
by  which  it  escaped.  To  do  this  it  is  necessary  to  know  in  what 
direction  the  head  of  the  bone  looks  in  any  particular  position  of 
the  hmb — a  point  easily  determined  by  remembering  that  the 
articular  surface  of  the  head  looks  very  nearly  in  the  same  direc- 


436 


INJURIES   OF   REGIONS. 


tion  as  the  internal  condyle.  It  must  be  further  remembered 
that  by  rotation  is  meant  the  rolling  of  the  femur  on  its  own  axis  ; 
that  in  outward  rotation  the  anterior  surface  of  the  patella  is 
rolled  outwards,  and  in  inward  rotation  inwards;  that  by  circum- 
duction is  meant  the  revolving  of  the  femur  round  the  axis  of  its 
head,  and  that  in  this  movement  the  anterior  surface  of  the 
patella  always  looks  to  the  front.  During  the  manipulation  the 
patient  should  be  placed  upon  his  back  on  the  floor,  while  the 
Surgeon  with  one  hand  should  grasp  the  ankle,  and  with  the  other 
the  thig'i  or  leg.  and  put  the  limb  through  the  several  movements 
required  for  the  kind  of  dislocation.  An  assistant,  if  necessary, 
should  fix  the  pelvis.  For  the  dislocation  on  the  dorsum  ilii  and 
into  the  sciatic  notch  the  movements  are  practically  the  same 
(Fig.  i8i).  The  limb  should  be  flexed  and  slightly  adducted  to 
disengage  the  head  from  behind  the  acetabulum,  and  then  ab- 
ducted, rotated  outwards  and  brought  down  parallel  to  the  sound 
limb.  These  movements  are  tersely  described  by  Bigelow  in  the 
words  'lift  up,'  'bend  out,'  'roll  out,'  /.  <?.,  lift  up  or  flex — bend 
out  or  abduct — loll  out  or  rotate  outwards.  The  head  is  thus 
compelled  to  revolve  round  a  centre  formed  by  the  great  tro- 
chanter, which  is  held  in  position  by  the  outer  branch  of  the  Y 
ligament.     In  the  thyroid  (Fig.  182)   the  thigh  should  be  flexed 


Fig.  181. 


Fig.  182. 


Method  of  reducing  llie  dors:il  and 
sciacic  di.sli)cntion.s  of  the  liip  by 
manipulations. 


(Afier  I'IkcIow.) 


Method  of  reducing  the  pubic  and 
thyroid  dislocations  of  tne  hip  by 
niaiiipiilation. 


and  sliglUly  abducted,  then  rotated  forcibly  inwards  and  adducted, 
and  brought  down  parallel   to  the  sound  thigh.     'I'he  head  is  thus 


REDUCIION    BY    TRACTION.  437 

made  to  retrace  its  steps  towards,  and  re-enter  the  acetabnlum, 
the  Y  ligament  being  wound  up.  as  it  were,  and  so  put  on  the 
stretch.  In  \\\^  pubic  the  reduction  is  accompUshed  in  a  manner 
similar  to  that  employed  for  the  thyroid. 

2.  Reduction  b\  traction  with  the  limb  in  the  flexed po'^ition. — 
The  flexion  of  the  limb  has  for  its  aim  the  relaxing  of  the  Y  ligament 
and  other  ligaments  and  tendons  that  impede  reduction,  and  then 
drawing  the  head  of  the  bone  directly  into  its  socket.  In  the  dorsal 
dislocation  the  thigh  should  be  flexed  at  a  right  ang^e  to  the  body, 
and  traction  then  made  in  an  upward  direction,  slightly  adducting 
and  rotating  inwards  to  disengage  the  head  from  behind  the 
acetabulum.  Counterpressure  may  be  made,  if  necessary,  by  the 
Surgeon  placing  his  unbooted  foot  on  the  anterior  iliac  spine  whilst 
drawing  or  jerking  the  limb  upwards.  If  on  flexion  it  is  found 
that  the  limb  cannot  be  abducted  beyond  the  perpendicular  with 
the  body,  the  hole  in  the  capsule  is  probably  too  sm.all  to  allow 
of  the  head  being  replaced.  It  may  readily  be  enlarged  by  cir- 
cumducting the  flexed  thigh  outward  across  the  abdomen.  The 
pulleys  may  be  used  if  more  force  is  required,  the  patient  then 
being  laid  on  his  sound  side  and  counter-extension  applied  to  the 
pelvis  by  a  leather  band  secured  to  the  wall ;  or  the  patient  may 
be  placed  on  his  back,  the  pelvis  secured  to  the  floor,  and  the 
pulleys  attached  to  a  staple  in  the  ceiling.  In  the  sciatic  the 
same  method  should  be  adopted,  as  the  flexion  frees  the  head  of 
the  bone  from  the  tendon  of  the  obturator  internus  which  winds 
round  its  neck,  and  together  with  the  Y  ligament,  which  is  also  re- 
laxed by  flexion,  is  the  chief  obstacle  to  reduction.  In  the  thyroid 
the  limb  should  be  flexed  and  abducted,  and  the  head  of  the  bone 
drawn  towards  the  socket,  counter- pressure  being  made,  if  re- 
quired, by  the  unbooted  foot  on  the  pelvis.  The  pulleys  may 
also  be  employed  in  this  position  if  more  force  is  required.  In 
the  pubic  the  limb  should  be  flexed  on  the  pelvis,  whilst  the  head 
is  drawn  down  towards  the  acetabulum  by  a  jack-towel  passed 
round  the  upper  third  of  the  thigh.  At  the  same  time  the  Umb 
should  be  rotated  slightly  inwards. 

3.  Reduction  by  traction  icnth  the  limb  in  the  extended  position 
is  the  method  recommended  by  Sir  Astley  Cooper,  but  is  one 
which  is  now  seldom  used  except  in  long-standing  cases.  It  has 
for  its  object  the  drawing  of  the  head  of  the  femur  directly  into 
the  acetabulum  by  main  force,  rupturing  any  ligaments,  muscles, 
or  tendons  that  offer  impediment.  The  extending  force  is  made 
in  the  line  of  the  dislocated  femur,  generally  by  means  of  the  pul- 
leys, which  are  usually  secured  to  the  lower  third  of  the  thigh  by 
a  padded  leather  band,  counter-extension  being  made  simultane- 
ously, and  in  the  same  straight  line  as  the  extension,  by  fixing  the 


438 


INJURIES   OF   REGIONS. 


pelvis  by  means  of  a  perineal  band,  secured  by  suitable  straps  to 
a  staple  in  the  wall  or  floor.  The  patient  should  be  placed  on  a 
low  couch  or  on  a  mattress  on  the  floor.  The  line  of  extension 
and  counter-extension  differs  according  to  the  form  of  dislocation. 
Thus  : — In  the  dorsal  (Fig.  183 ),  extension  should  be  made  across 


Reduction  of  dorsal  dislocations  by  pulleys  in  extended  position.     (Cooper's  Dislocations.) 

the  lower  third  of  the  sound  thigh,  the  pulleys  being  fixed  to  a 
staple  in  the  wall  a  few  feet  from  the  foot  of  the  couch  above  the 
level  of  the  body,  and  the  counter-extension  band  to  a  staple  in  the. 
floor  near  the  head  of  the  couch.     In  the  sciatic  (Fig  184),  the 


!   1  ■  II    ^IKl 

Reduction  of  sciatic  dislocation  by  pulleys  in  extended  position.     (Cooper's  Dislocations.) 

extension  is  made  in  a  nearly  similar  direction,  save  that  the  thigh 
should  be  more  flexed.  In  the  thyroid  (Fig,  1S5),  extension  is 
made  in  an  upward  and  outward  direction,  by  means  of  a  perineal 
band  passed  round  the  upi)er  pait  of  the  dislocated  thigh  and  at- 
tached to  pulleys  fixed  to  a  staple  in  the  wall  on  the  injured  side. 
Counter-extension  is  made  by  a  band  passed  round  the  pelvis  and 
secured  to  a  staple  in  the  floor  on  the  sound  side.  The  ankle,  in 
the  meantime,  is  drawn  towards  the  mesial  line  of  the  body,  by  the 


THE   PATELLA. 


439 


Fig.  185. 


Surgeon's  hand  passed  behind  the  sound  Hmb.  The  Une  of  ex- 
tension and  counter-extension  here  runs  obhquely  across  the 
body.  In  the  pubic  (Fig.  186),  extension  is  made  downwards  and 
outwards  by  pulleys  attached  to  a  staple  in  the  floor,  counter- 
extension  being  made  by  the  perineal  band,  which  is  carried  up- 
wards and  inwards  across  the  opposite  shoulder,  and  attached  to 
a  staple  in  the  wall.  After  the  extension  has  been  applied  some 
time  the  head  of  the  bone  may 
be  hfted  over  the  edge  of  the 
acetabulum  by  a  jack-towel,  the 
thigh,  if  necessary,  being  rotated 
inwards  at  the  same  time. 

4.  Reduction  by  open  incision 
has  of  late  been  practised  suc- 
cessfully in  cases  of  long  standing 
where  manipulation  and  exten- 
sion have  failed.  The  head  of 
the  bone  having  been  exposed  it 
is  freed  from  fibrous  bands  and 
adhesions,  the  acetabulum  is 
cleared  of  any  fibrous  tissue  that 
may  be  found  filling  it,  and  the 
head  of  the  bone  replaced. 

The  Patella  may  be  dislocated 
outwards,  inwards,  upwards,  and 
edgeways.  The  outward  disloca- 
tion is  the  most  common ;  the 
upward  variety  can  only  occur 
when  the  ligamentum  patellae  has 
been  ruptured  or  divided.  The 
outward  and  inward  varieties  may 
be  complete  or  incomplete.  In 
the  dislocation  edgeways,  which 

is  very  rare,  the  patella  rests  vertically  on  one  edge  between  the 
cond3'les,  either  the  outer  or  the  inner  edge  looking  forwards,  but 
most  commonly  the  former.  Cause. — Muscular  action,  or  a  blow 
on  the  outer  or  inner  edge  of  the  bone.  Knock-knee  predisposes 
to  the  outward  dislocation.  The  signs  are  obvious,  the  position 
of  the  patient  indicating  the  nature  of  the  accident.  Treatmetit. 
— Vvith  the  patient  anesthetized,  the  thigh  should  be  flexed  on 
the  abdomen,  to  relax  the  quadriceps  extensor  muscle  ;  and  the 
leg,  for  the  same  p.irpose,  extended  on  the  thigh.  In  the  out- 
ward and  inward  dislocation,  pressure  should  now  be  made  on  the 
edge  of  the  patella  that  is  further  from  the  centre  of  the  joint,  so  as 
to  raise  the  opposite  edge  and  tilt  it  over  the  condyle,  when  it  is 


Reduction  of  thyroid   dislocation  by  pul- 
leys.    (Cooper's  Dislocations.) 


440 


INJURIES    OF    REGIONS. 


at  once  drawn  into  place  by  the  action  of  its  muscles.  In  the 
edgeways  variety,  pressure  should  be  made  with  the  thumbs  in 
opposite  directions  on  the  upper  and  lower  margin  of  the  dis- 
located bone,  this  manipulation  being  aided  by  suddenly  and 
forcibly  flexing  the  knee,  and  then,  if  necessary,  by  extending  it. 
Reduction,  though  generally  easy,  is  sometimes  attended  with 
great  difificulty,  and  has  occasionally  been  found  impossible,  even 


Fig 


Reduction  of  pubic  dislocation  by  pulleys  in  extended  position.     (Cooper's  Dislocations.) 

after  subcutaneous  division  of  ligaments  and  tendons.  Effusion 
into  the  joint  generally  follows,  and  should  be  treated  in  the  usual 
way.  After  reduction  the  joint  should  be  placed  on  a  back  splint 
or  in  plaster-of- Paris,  and  a  knee-cap  subsequently  worn  to  pre- 
vent a  recurrence  of  the  dislocation. 

Partial  dislocation  of  the  patella,  the  result  of  an  elongated 
patellar  ligament,  sometimes  occurs.  The  elongation  of  the  liga- 
ment allows  the  patella  to  be  placed  on  the  femur  when  the  knee 
is  flexed  so  that  its  anterior  surface  looks  directly  upwards.  As  a 
consequence  of  the  elongation  of  the  ligament,  the  patella  from 
time  to  time  is  apt  to  slip  suddenly  over  one  or  other  condyle, 
causing  the  patient  to  fall.  In  two  cases  I  succeeded  in  curing 
the  condition  by  transplanting  the  tubercle  of  the  tibia  lower  down 
the  shaft  of  the  bone,  thus  shortening  the  ligament  half  an  inch  to 
an  inch  according  to  the  amount  of  elongation.  The  author's 
method  of  transplanting  the  tubercle  will  be  understood  by  refer- 
ring to  figure  187.  The  tubercle  was  fixed  in  its  new  situation  by 
an  ivory  peg. 

The  Knee. — Dislocation  of  the  knee  is  exceedingly  rare.  It 
may  occur  in  a  forward,  backward,  inward,  and  outward  direction, 
and  in  any  case  may  be  complete  or  incomplete.  Cause. — 
Usually  great  violence,  as  a  severe  wrench  or  twist  of  the  joint. 
Si^ns. — In  the  lateral  dislocations,  which  are  generally  incom- 
plete, a  projection  caused  by  the  condyles  of  the  femur  on  the 


THE    KNEE. 


441 


one  side,  with  a  depression  below,  and  a  projection  of  the  tibia, 
or  of  the  fibula,  as  the  case  may  be,  on  the  opposite  side,  with  a 
depression  above,  at  once  show  the  nature  of  the  injury.  In  the 
antero-posterior  varieties,  which  are  generally  complete,  there  is 
great  shortening  and  deformity  of  the  Hmb  ;  the  head  of  the  tibia 
in  the  forward  dislocation  projects  anteriorly;  whilst  in  the  back- 
ward it  can  be  felt  in  the  ham.  In  the  former  there  is  generally 
considerable  sweUing  and  congestion,  and  often  pain  in  the  limb 


BURSA   I 


Fig.  187. 

; TRANSVERSE  CUT 

lOBLIQUE  cur. 


Author's  method  < 


tiiii;  llie  tubercle  of  the  tibia  for  the  purpose  of  shortening  an 
elongated  patellar  ligament. 


below  the  knee,  from  pressure  of  the  condyles  of  the  femur  on 
the  popliteal  vessels  and  nerves.  Trea(me7it. — Reduction,  as  a 
rule,  is  easily  accomplished  by  extension,  combined  with  manipn 
lation  and  pressure  in  the  direction  indicated  by  the  variety  of 
the  dislocation.  The  limb  should  then  be  placed  on  a  back- 
splint,  and  an  ice-bag  apphed  to  the  knee,  passive  movements 
being  begun  at  the  end  of  two  or  three  weeks,  and  a  knee-cap 
subsequently  worn  for  twelve  months  at  the  least.  Compound 
dislocations  usually,  though  not  invariably,  call  for  amputation. 

Dislocation  of  one  of  the  seniiliinar  cartilages  of  the  knee, 
usually  the  internal,  may  occur  from  a  sudden  twist  or  wrench  of 
the  joint  during  semi-flexion.  The  accident  is  attended  with 
sudden  and  severe  pain,  a  "  locking  "  of  the  joint  usually  in  a  bent 
position,  and  the  presence  of  a  hollow,  sometimes  of  a  projection, 
over  the  site  of  the  semilunar  cartilage.  There  is  at  first  com- 
monly some  effusion  into  the  joint.     In  chronic  cases  the  patient 


442 


INJURIES    OF    REGIONS. 


Fig.  i8 


may  be  able  to  displace  and  replace  the  cartilage  at  will  by  twist- 
ing his  knee.  The  condition  may  closely  simulate  a  loose  body 
in  the  joint  or  a  nipped  synovial  fringe,  but  the  above  signs  will 
generally  suffice  to  distinguish  it.  The  diagnosis  is,  however, 
sometimes  difficult,  unless  the  patient  is  seen  at  the  time  the 
cartilage  is  displaced.  Treatment. — To  replace  the  cartilage,  flex 
the  thigh  on  the  abdomen  and  the  leg  on  the  thigh,  and  rotate 
the  leg  outwards ;  then  manipulate  the  cartilage  with  the  fingers 
and  suddenly  extend  the  leg,  at  the  same  time  rotating  it  out- 
wards. To  prevent  a  recurrence  the  movements  of  the  joint 
should  be  limited  to  flexion  and  extension  by  means  of  a  special 
form  of  clamp,  which  should  be  worn  for  a  year  or  longer.  In 
intractable  cases  in  which,  notwithstanding  the  use  of  the  above 
instrument,  the  cartilage  is  constantly  being  dislocated,  the  joint 
may  be  opened  and  the  cartilage  fixed  by  sutures  or  removed. 

The  Ankle. — The  astragalus,  together  with  the  rest  of  the 
bones  of  the  foot,  may  be  dislocated  from  the  socket  formed  for 
it  by  the  tibia  and  fibula,  in  an  outward,  inward,  backward,  for- 
ward, or  upward  direction.  All  five  varieties  are  generally  com- 
plicated by  fracture  of  the  fibula,  or  of  the  internal  malleolus. 
The  outiuard  and  inward  varieties  will 
be  described  under  the  head  of  fracture 
of  the  fibula  (see  p.  456.)  The  back- 
ward and  forward  varieties  are  rare ; 
the  latter  especially  so.  In  the  former 
(Fig.  188),  the  astragalus  is  either  par- 
tially or  completely  driven  backwards 
from  its  socket,  carrying  with  it,  of 
course,  the  other  bones  of  the  foot ;  so 
that  the  foot  appears  shortened,  the 
heel  prominent,  and  the  tendo  Achillis 
tense.  In  the  forward  variety  the 
astragalus  is  generally  forced  only  par- 
tially from  between  the  malleoli,  and 
the  foot  appears  lengthened,  the  heel 
less  prominent  than  natural,  and  the 
tendo  Achillis  relaxed.  In  the  upivard 
variety  the  tibia  and  fibula  are  torn 
asunder,  and  the  astragalus  is  forced 
upwards  between  them.  ']"he  ankle 
appears  widened,  the  malleoli  are  almost  in  contact  with  the 
ground,  and  all  motion  at  the  ankle-joint  is  lost.  Treatment. — 
The  leg  having  been  flexed  and  the  foot  extended  to  relax  the 
calf-muscles,  make  extension  on  the  foot  whilst  an  assistant  holds 
the  thigh,  and  then  manipulate  the  bones  into  position.     If  neces- 


Dislocation  of  the  foot  backwards. 
.'St.  Bartholomew's  Hospital 
Museum.) 


THE    SUBASTRAGALOID    DISLOCATION.  443 

sary,  give  an  anaesthetic,  and  cut  the  tendo  Achillis.  Place  the 
foot  and  leg  on  a  back-splint,  or,  if  preferred,  on  a  Chne's  or 
Dupuytren's  splint. 

Compound  dislocation  of  the  ankle. — In  young  and  healthy 
subjects  an  attempt  should  be  made  to  save  the  foot,  unless  the 
main  vessels  are  torn,  or  there  is  much  comminution  of  the  bones, 
or  extensive  laceration  of  the  soft  parts,  when  amputation  is  the 
safer  course.  Resection  of  the  bones,  however,  may,  in  some 
instances,  be  undertaken  with  advantage  ;  but  each  case  must  be 
judged  on  its  merits,  and  the  indications  for  resection  cannot  be 
discussed  here. 

The  astragalus  may  be  dislocated  from  the  tibia  and  fibula 
above  and  from  the  os  calcis  and  scaphoid  below  and  in  front,  in 
a  forward,  backward,  inward  or  outward  direction ;  whilst  very 
rarely  it  may  be  rotated  on  its  own  axis  either  vertically  or  hori- 
zontally. The  forward  dislocation,  which  is  generally  produced 
by  a  wrench  of  the  extended  foot,  is  the  most  common,  the  bone 
in  this  variety  usually  inclining  either  a  little  outwards,  or  a  little 
inwards  at  the  same  time.  The  backward  dislocation  most  often 
occurs  from  a  wrench  when  the  foot  is  flexed.  The  lateral  dis- 
locations when  complete  are  always  compound,  and  nearly  always 
associated  with  fracture  of  the  malleoH.  Signs. — The  astragalus 
in  the  forward  variety  can  be  felt  projecting  under,  and  often 
threatening  to  ptotrude  through  the  skin  of  the  instep  ;  whilst  in 
the  backward  form  it  gives  rise  to  a  prominence  beneath  the  tendo 
Achillis  which  it  causes  to  bulge  backwards,  to  shortening  of  the 
foot,  and  to  a  projection  of  the  tibia  in  front.  The  lateral 
varieties  being  compound,  the  nature  of  the  injury  is  obvious. 
Treatment. — In  the  simple  form  attempts  should  always  be  made 
to  push  back  the  displaced  bone  into  its  socket  by  making  pres- 
sure in  the  proper  direction,  the  calf-muscles  being  relaxed  by 
position,  the  foot  extended,  and  the  tendo  Achillis,  or  any  other 
tendon  or  ligament  that  is  felt  tense,  divided  if  necessary.  An 
angesthetic  is  generally  required.  If  reduction  is  then  found  im- 
possible, the  rule  is  to  leave  the  displaced  bone  alone,  and  only 
to  excise  it  if  sloughing  threatens  or  has  actually  occurred.  See- 
ing, however,  how  successful  are  the  results  of  excision  of  the 
astragalus  for  intractable  cases  of  club-foot,  I  should  myself,  if  I 
failed  to  reduce  the  bone,  remove  it  at  once.  In  a  compound 
dislocation  the  bone  should,  as  a  rule,  be  excised. 

The  SUBASTRAGALOID  DISLOCATION  is  ouc  in  which  the  bones  of 
the  foot  are  displaced  from  the  astragalus,  which  itself  retains  its 
natural  connections  with  the  tibia  and  fibula.  The  foot  is  gen- 
erally displaced  either  backwards  and  inwards,  or  backwards  and 
outwards  ;  more  rarely  in  the  opposite  directions.     In  the  back- 


444 


INJURIES   OF   REGIONS. 


Fig. 


ward  and  inward  variety  (Fig.  1S9)  the  foot  is  inverted,  the  sole 
looks  inwards,  the  external  malleolus  is  prominent,  the  internal 
malleolus  is  buried  b}'  the  projection  of  the  os  calcis  beyond  it, 
and  the  head  of  the  astragalus  forms  a  distinct  prominence  on  the 
outer  side  of  the  instep,  over  which  prominence  the  skin  is  tightly 
stretched.  In  the  backward  and  outward  variety  the  foot  is 
everted  instead  of  inverted,  the  internal 
malleolus  is  prominent,  the  external  buried, 
and  the  astragalus  projects  on  the  inner 
side  of  the  instep.  The  forward  varieties 
are  too  rare  to  require  description.  The 
normal  relations  of  the  head  of  the  astrag- 
alus to  the  malleoli,  together  with  the  signs 
above  given,  will  serve  to  distinguish  it 
from  dislocation  of  the  astragalus  alone,  the 
injury  with  which  it  is  most  liable  to  be 
confounded.  Treatment. — In  the  back- 
ward varieties  the  foot  should  be  drawn 
forwards,  whilst  the  leg  is  forced  backwards, 
the  tendo  Achillis  and  the  tibialis  anticus 
and  posticus  being  divided  if  necessary, 
and  the  patient  put  under  an  anaesthetic. 
Reduction  is  sometimes  very  difficult  or 
even  impossible,  in  consequence  of  the  tibial 
tendons  hooking  round  the  head  of  the 
astragalus,  or  of  the  mutual  interlocking  of  the  bones.  After 
reduction  the  foot  should  be  placed  on  a  splint,  and  an  ice-bag 
applied.  If  sloughing  occurs,  Firogoff's  or  Syme's  operation  may 
have  to  be  performed. 

Dislocation  of  the  separate  rones  of  the  tarsus,  of  a  he 

METATARSAL    BONES,    AND    OF  THE  PHAI ANGES   OF    'fHE    JOES,    are  tOO 

rare  to  require  special  description. 


Subastragaloid  dislocation. 
(St.  Bartholomew's  Hos- 
pital Museum. J 


Fractures  of  the  Lower  Extremity. 

Fractures  of  the  femur  may  be  divided  into  fractures  of — I. 
the  upper  end ;  II.  the  shaft;  and  III.  the  lower  end. 

I.  Fractures  of  the  upper  enb  of  the  femur  may  be  divided 
into — I,  intracapsular  fracture  of  the  neck  ;  2,  extracapsular  frac- 
ture of  the  neck  ;  3,  fracture  of  the  great  trochanter;  and  4,  sep- 
aration of  the  epiphysis  of  the  head. 

I.  Intracapsular  fracture  occurs  most  frequently  in  the  old, 
and  more  commonly  in  women  than  in  men.  Cause. — The  atrophy 
and  fatty  degeneration  of  the  bone  and  the  diminished  obliquity 
of  the  neck  which  is  said  frequently  though  not  invariably  to 


INTRACAPSULAR  FRACTURE.  445 

attend  old  age,  are  the  chief  predisposing  causes.  Professor 
Humphry  maintains,  however,  that  there  is  no  diminution  of  ob- 
liquity as  age  advances.  Slight  indirect  violence,  such  as  slipping 
off  the  curbstone,  catching  the  toes  in  the  carpet,  etc.,  is  the 
common  exciting  cause. 

State  of  the  parts. — The  line  of  fracture  may  be  situated  at  any 
part  of  the  neck  within  the  capsule,  and  may  be  transverse  or 
oblique  ;  the  usual  situation,  however,  is  just  external  to  the  head, 
and  the  direction  transverse.  The  fragments  may  be  impacted  or 
non-impacted,  but  impaction  is  the  exception.  In  the  impacted 
form  the  lower  fragment  is  nearly  always  driven  into  the  upper  ; 
when,  however,  the  fragments  are  very  jagged,  mutual  interlocking 
may  occur.  The  periosteum  covering  the  neck — the  cervical  re- 
flection, as  it  is  sometimes  called — may  be  partially  or  completely 
torn,  so  that  all  connection  between  the  head  and  the  rest  of  the 
bone  is  severed.  Upon  the  extent  of  its  rupture  will  in  part  de- 
pend the  amount  of  displacement  of  the  fragments,  and  the  kind 
of  union  that  will  occur.  In  the  non-impacted  form  the  lower 
fragment  with  the  rest  of  the  femur  is  drawn  slightly  upwards  by 
the  muscles  inserted  into  the  trochanters,  and  at  the  same  time 
generally  rotated  outwards.  The  outward  rotation  would  appear 
to  depend  in  part  on  the  direction  of  the  line  of  fracture,  and  in 
part  on  the  weight  of  the  limb,  which  has  a  natural  tendency  to 
roll  outwards.  Method  of  uiiion. — In  consequence  partly  of  the 
feeble  blood  supply  of  the  upper  fragment,  and  partly  of  the  frag- 
ments not  being  in  apposition,  bony  union  seldom  occurs,  the 
parts  becoming  bound  together  by  fibrous  tissue  or  remaining  un- 
united. In  the  latter  case  the  fragments  become  rounded  oif  and 
polished,  forming  a  false  joint ;  whilst,  owing  to  the  absorption  of 
the  lower  fragment,  great  shortening  of  the  neck  usually  ensues. 

Signs. — Slight  shortening — about  three-quarters  of  an  inch — 
eversion,  inability  to  raise  the  limb  from  the  horizontal  position, 
approximation  of  the  great  trochanter  to  the  anterior  superior 
spine  of  the  ilium,  rotation  of  the  great  trochanter  through  a 
smaller  arc  than  on  the  opposite  side,  and  crepitus,  are  the  usual 
signs.  Occasionally  there  may  be  no  shortening  at  first,  and 
patients  have  been  known  to  walk  after  the  injury.  In  rare 
instances  there  has  been  inversion  instead  of  eversion,  a  fact  not 
easy  of  explanation.  In  the  impacted  form  there  is  no  crepitus, 
the  shortening  is  less,  and  does  not  disappear  on  extension,  and 
the  patient  may  be  able  to  raise  the  limb  from  the  horizontal 
position,  and  perhaps  stand  or  walk  on  it.  Diagnosis. — The  age 
of  the  patient,  the  very  slight  shortening,  the  absence  of  bruising 
about  the  trochanter,  the  slightness  of  the  violence  occasioning  it, 
and  the  eversion  of  the  limb,  are  the  chief  signs  which  point  to 


446  INJURIES   OF   REGIONS. 

intracapsular  fracture ;  but  it  may  have  to  be  diagnosed  from  the 
extracapsular  form,  from  dislocation  of  the  hip,  from  dislocation 
with  fracture  of  the  acetabulum,  from  chronic  osteo  arthritis,  and 
from  mere  contusion  of  the  hip.  In  the  extracapsular  form  the 
shortening  is  greater,  the  patient  usually  younger,  the  occasioning 
violence  direct  and  more  severe,  and  there  is  often  bruising  and 
ecchymosis  of  the  skin  and  widening  of  the  trochanter.  In  dis- 
location there  is  loss  of  mobility  of  the  limb,  and  the  head  of  the 
bone  can  be  felt  in  the  abnormal  position.  The  only  common 
dislocation  with  which  the  ordinary  form  of  fracture  could  be 
confounded  is  the  pubic,  as  in  this  alone  is  there  any  eversion ; 
but  here  the  distinct  prominence  formed  by  the  head  of  the  bone 
on  the  pubes  at  once  serves  to  distinguish  it.  In  fracture  of  the 
acetabulum  with  dislocation  there  is,  in  addition  to  crepitus,  the 
presence  of  the  head  of  the  bone  in  an  abnormal  situation,  whence 
it  can  be  drawn  on  extension  of  the  limb,  but  returns  when  the 
extension  is  relaxed,  crepitus  during  these  movements  being  felt. 
Chronic  osteo-arthritis,  in  which  in  consequence  of  the  absorption 
of  the  head  of  the  bone  there  is  often  shortening  and  eversion, 
and  in  consequence  of  the  movement  of  the  osteophytes  upon 
each  other  crepitus,  may  be  distinguished  from  intercapsular 
fracture,  which  it  may  simulate  should  a  patient  suffering  from  it 
have  a  fall,  by  the  history  of  pain,  lameness,  and  stiffness  before 
the  injury.  In  contusion  of  the  hip,  though  there  may  be  eversion 
of  the  limb  and  loss  of  power,  the  trochanter  retains  its  normal 
relations,  and  there  is  no  shortening  or  crepitus.  It  should  be 
remembered,  however,  that  in  old  people  absorption  of  the  neck 
of  the  bone  may  slowly  take  place  after  a  contusion,  and  of  this 
the  patient  should  be  warned,  as  otherwise  the  Surgeon  may  be 
accused  of  overlooking  a  fracture. 

The  treatment  should  vary  according  to  the  age  and  powers  of 
the  patient.  Thus  in  the  old  and  feeble  in  whom  bony  union  can 
scarcely  be  expected,  and  in  whom,  moreover,  long  confinement 
on  the  back  is  liable  to  produce  bed-sores  and  even  fatal  hypo- 
static congestion  of  the  lungs,  the  limb  should  be  merely  placed  at 
rest  between  sand-bags,  and  the  j^atient  only  confined  to  bed  for 
a  few  days.  He  should  then  be  allowed  to  get  about  on  crutches 
with  the  parts  secured  in  some  form  of  stiff  bandage  or  moulded 
leather  case,  or  on  a  Thomas's  hip-joint  splint.  In  younger  and 
fairly  vigorous  patients  an  attempt  may  be  made  to  obtain  bony 
union,  either  by  means  of  extension  with  the  weight  and  i)ullcy  or 
by  the  long  splint.  Confinement  to  bed  for  six  or  eight  weeks  is 
usually  necessary,  followed  for  another  two  or  three  months  by 
the  use  t)f  some  form  of  stiff  apparatus. 

2.  ExTRACAPSui-AK  I'KACTURES,  though  morc  frccpient  in  the  old 


EXTRACAPSULAR  FRACTURE.  447 

than  in  the  young,  are  not,  like  intracapsular  fractures,  so  essen- 
tially an  injury  of  old  age.  Thus,  they  are  frequently  met  with 
between  the  ages  of  forty  and  fifty,  whereas  intracapsular  fractures 
hardly  ever  occur  in  persons  under  fifty.  Cause. — Usually  direct 
violence,  as  a  fall  or  a  severe  blow  on  the  great  trochanter.  State 
of  the  parts. — The  fracture  commonly  extends  through  the  base 
of  the  neck  just  outside  the  capsule,  and  is  nearly  always  asso- 
ciated with  a  fracture  of  the  great  trochanter.  It  may  be  im- 
pacted or  non-impacted,  the  former  condition,  however,  being  by 
far  the  most  common.  Indeed,  it  is  probable  that  nearly  all 
extracapsular  fractures  are  in  the  first  instance  impacted  and  ac- 
companied by  fracture  through  the  great  trochanter,  and  that  they 
only  become  non-impacted  by  the  spHtting  asunder  of  the  tro- 
chanters, in  consequence  of  the  neck  being  driven  in  still  further 
wedge-wise,  between  them  ;  and  hence  that  non-impaction  only 
occurs  as  a  result  of  great  violence.  The  line  of  fracture  through 
the  trochanter  commonly  extends  obliquely  downwards  and  back- 
wards, and  terminates  by  passing  through  the  trochanter  minor; 
but  it  may  take  various  directions,  sometimes  splitting  the  tro- 
chanter into  several  pieces.  The  method  of  union  is  generally 
bony,  and  as  the  blood  supply  is  very  good,  there  is  often  an  ex- 
cessive formation  of  callus.  In  rare  instances  no  union,  or  fibrous 
union,  occurs. 

The  signs  are  similar  to  those  of  the  intracapsular  variety.  Thus, 
there  is  eversion  and  shortening  of  the  hmb,  pain  on  movement, 
inability  as  a  rule  to  raise  the  limb  from  the  ground,  and  the  top 
of  the  trochanter  is  found  to  be  above  Nelaton's  line  (Fig.  177), 
and  the  base  of  Bryant's  triangle  to  be  less  than  on  the  sound  side. 
But  the  shortening  is  greater  than  in  intracapsular  fracture  ;  the 
patient  is  commonly  not  so  old ;  the  fracture  is  probably  pro- 
duced by  direct  violence  ;  the  trochanter  feels  enlarged  and 
thicker  than  that  of  the  opposite  side,  from  being  split  by  the 
neck ;  there  is  swelling  and  bruising  about  the  hip  ;  and  often 
much  subsequent  ecchymosis,  since  the  blood  being  outside  the 
capsule  readily  makes  its  way  to  the  surface.  In  the  non-impacted 
variety  where  there  is  much  comminution  of  the  trochanter,  the 
shortening  may  be  as  much  as  two  or  three  inches,  and  crepitus 
will  be  well  marked.  In  the  impacted,  the  shortening  is  much 
less,  seldom  exceeding  an  inch,  and  crepitus  cannot  be  elicited, 
unless  the  fragments  are  loosely  wedged.  In  firm  impaction, 
indeed,  the  patient  can  often  raise  the  leg,  or  even  walk. 

l^reatment. — In  the  non-impacted  variety,  extension  should  be 
applied  by  means  of  some  variety  of  Liston's  long  splint,  a  stirrup, 
weight  and  pulley  being  substituted,  if  preferred,  for  the  perineal 
band.     Firm  osseous  union  will  generally  be  obtained  in  a  month 


44S 


INJURIES   OF    REGIONS. 


Fig.  ig 


to  six  weeks.  In  the  impicled,  extension  had  better  not  be 
made,  but  the  Hmb  merely  kept  at  rest  by  the  long  splint  till  the 
swelling  and  pain  have  subsided,  and  the  patient  then  allowed  to" 
get  about  on  crutches.  Firm  union  will  occur,  but  there  will  be 
permanent  shortening,  and  probably  some  evcrsion  and  stiffness 
of  the  joint. 

3.  Fracture  of  the  great  trochanter  ;  and  4,  Separation 
OF  the  epiphysis  of  the  head,  are  too  rare  to  call  for  description 
here. 

II.  Fractures  of  the  shaft  of  the  femur  are  very  common 
in  children,  less  common  in  adults,  and  rare  in 
old  people,  in  whom  intra-  and  extracapsular 
fractures  more  readily  occur.  Cause. — Gen- 
erally the  result  of  indirect  violence,  occasion- 
ally of  direct,  and  rarely  of  muscular  action. 
State  of  the  parts. — The  line  of  fracture  is 
usually  transverse  or  oblique  ;  but  in  rare  in- 
stances, almost  longitudinal  or  spiral.  The 
oblique  is  more  common  in  adults ;  the  trans- 
verse in  children.  The  fragiiients  for  the  most 
part  considerably  overlap,  producing  much 
shortening.  The  usual  situation  of  the  fracture 
is  about  the  middle  of  the  bone,  though  it  may 
occur  through  the  upper  or  middle  or  lower 
third.  In  the  upper  third  (Fig.  190),  the  lower 
end  of  the  upper  fragment  is  drawn  forwards  by 
the  psoas  and  iliacus,  and  at  the  same  time, 
generally  abducted  and  rotated  outwards  by  the 
glutei  and  external  rotator  muscles.  The  up])er 
end  of  the  lower  fragment  is  drawn  inwards  by 
the  adductors,  and  upwards  by  the  quadriceps 
and  hamstrings,  whilst  it  is  also  rotated  out- 
wards in  part  by  the  adductors,  and  in  part  by 
the  weight  of  the  limb.  Ocasionally,  the 
upper  fragment  is  drawn  inwards  instead  of  out- 
wards. Union  is  apt  to  occur  with  some  over- 
lapping of  the  fragments  anl  angukir  deformity.  In  the  middle 
third  the  displacement  is  similar,  the  upper  fragment  usually  pro- 
jecting in  front  and  to  the  outer  side  of  the  lower.  In  the  lower 
third  the  upj^er  fragment,  in  addition  to  being  displaced  for- 
wards, is  generally  drawn  towards  the  middle  line  by  the  ad- 
ductors ;  whilst  the  lower  fragment,  especially  when  the  fracture 
is  just  above  the  condyles,  is  tilted  backwards  into  the  jiopliteal 
space  by  the  gastrocnemius,  where  it  can  be  felt  as  a  distinct 
prominence,  and  at  the  same  lime  is  drawn  uj^wards  with  the  rest 
of  the  limb  by  the  hamstrings  and  quadriceps  (Fig.  191). 


Fracture  of  upper 
third  of  femur. 
(After  Gray.) 


FRACTURES    OF    THE    SHAFT    OF   THE    FEMUR. 


449 


Fig.  191. 


Signs. — In  the  adult  the  signs  are  usually  very  obvious.  They 
consist  in  shortening,  crepitus,  eversion  of  the  foot,  swelling  from 
the  approximation  of  the  attachments  of  the  mus- 
cles, and  in  preternatural  mobility  and  loss  of 
power  in  the  limb.  The  ends  of  the  fragments, 
moreover,  can  often  be  felt  on  manipulation.  In 
young  children  the  diagnosis  is  net  always  so  easy, 
especially  when  the  fracture  is  incomplete  ;  the 
bowing  of  the  limb,  shortening,  sensation  of  yield- 
ing or  creaking,  and  the  history  of  the  accident, 
however,  will  usually  prevent  a  mistake. 

Treatment. — The  methods  of  treating  fractures 
of  the  shaft  of  the  femur  are  very  numerous ;  they 
have  all  for  their  object  the  extension  of  the  limb. 
Extension  overcomes  the  spasmodic  contraction 
of  the  hamstrings  and  adductors,  and  through  the 
insertion  of  the  quadriceps  into  the  anterior  sur- 
face of  the  upper  fragment  draws  the  lower  end 
of  the  latter  backwards,  thus  counteracting  the 
psoas  and  iliacus.  The  various  methods  may  be 
briefly  considered  under  the  following  heads  : — i, 
the  long  splint;  2,  the  weight  and  pulley  ;  3,  the 
double-inclined  plane ;  4.  the  plaster-of- Paris  or  starch  bandage. 

I.  The  long  splint  (Fig.  192)  in  its  simplest  form  consists  of  a 
straight  lath  with  two  notches  at  its  lower,  and  two  holes  in  its 
upper  end,  and  is  known  as  Liston's.     It  should  reach  from  the 


Fnctiire  of  lower 
third  of  femur. 
(After  Gr.-iy.) 


Fig.  192. 


Liston's  long  splint.     (Heath's  Minor  Surgery.) 


axilla  to  six  inches  below  the  foot.  The  splint,  well  padded,  is 
first  bound  to  the  foot  and  leg  by  a  bandage  carried  through  the 
notches  in  the  splint,  and  over  the  ankle  in  the  form  of  a  figure 
of  8,  and  then  up  the  leg,  and  beyond  the  knee  to  prevent  relax- 
ation of  the  ligaments  of  the  joint  (Fig.  192).  A  perineal  band 
having  been  previously  adjusted,  and  its  ends  brought  out  through 
the  holes  in  the  top  of  the  sphnt,  is  now  tightened,  whilst  exten- 
19* 


450 


INJURIES    OF    REGIONS. 


sion  is  made  upon  the  foot.  The  ends  of  the  perineal  band,  as 
soon  as  the  fracture  is  reduced,  are  securely  tied.  The  band  thus 
acts  as  a  counter-extending  force,  and  the  displacement  is  pre- 
vented from  returning.  A  broad  bandage  is  finally  passed  round 
the  thorax  to  confine  the  splint  to  the  side.  The  perineal  band 
may  consist  of  any  soft  material,  as  a  folded  silk  handkerchief,  or 
"  piece  of  bandage  sewn  in  the  form  of  a  long  bag  and  stuffed 
with  cotton  wool,"  with  tapes  attached  at  each  end.  It  should 
take  its  bearings  from  the  tuber  ischii,  and  not  rest  between  the 
tuber  ischii  and  great  trochanter,  as  here  it  would  press  on  the 
great  sciatic  nerve.  The  spUnt  is  improved  by  a  cross-bar  at  its 
lower  end,  to  prevent  the  limb  rolling  outwards,  and  by  an  oval 
aperture  opposite  the  external  malleolus,  to  prevent  pressure  on 
that  bone.  As  the  perineal  band  is  apt  to  chafe,  some  surgeons, 
in  its  place,  employ,  in  combination  with  the  long  splint,  the  stir- 
rup, weight  and  pulley  for  the  purpose  of  extension,  raising  the 
bed  at  the  foot  so  that  the  weight  of  the  body  may  act  as  the 

Fig.  193. 


Bryant's  splint. 


counter-extending  force.  Many  modifications  of  the  long  splint 
are  in  use  ;  amongst  these  may  be  mentioned  Boyer's,  Desault's, 
Bryant's,  and  De  Morgan's  splints.  Bryant's  (Fig.  193)  consists 
of  two  long  splints  united  above  and  below  by  iron  cross-bars  in 
the  way  shown  in  the  drawing,  and  interrupted  opposite  the  tro- 
chanters to  avoid  ])ressure  on  these  parts.  By  its  use  both  limbs 
are  kept  parallel,  and  abduction  or  adduction  of  the  fractured 
limb  is  prevented,  whilst  extension  is  kept  up  by  means  of  the 
elastic  apparatus  attached  to  the  side  of  the  splint,  and  connected 
by  cords  and  pulleys  to  the  foot  piece,  which  moves  up  and  down 
in  a  slot.  If  the  foot  of  the  bed  is  raised  no  penneal  band  is 
required. 

2.  The  wei^lit  ain/  pi///ry  is  frequently  used,  either  alone,  or  as 
an  addition  to  the  long  splint.  A  long  piece  of  strapping  is  se- 
cured on  each  side  of  the  leg  and  lower  third  of  the  thigh  by 
otrapjHng  and  a  bandage,  leaving  a  loop  about  eight  inches  long 


FRACTURES  OF  THE  LOWER  END  OF  THE  FEMUR. 


451 


Fig.  194. 


under  the  sole.  In  the  loop  thus  left  a  flat  piece  of  wood,  about 
two  inches  square,  is  placed,  and  through  a  hole  in  the  centre  of 
this  a  cord  is  passed  and  secured  by  a  knot  at  its  end.  The  cord 
is  then  carried  over  a  pulley  at  the  foot  of  the  bed,  and  a  weight 
of  several  pounds  suspended  on  it.  The  weight  should  be  gradu- 
ally increased  till  the  fractured  limb  is  found  on  measurement  to 
be  the  same  length  as  the  sound  limb.  Ten  to  twenty  pounds  or 
even  more  may  be  required.  Counter-extension  is  made  by  the 
weight  of  the  body,  the  foot  of  the  bed  being  raised  six  inches  or 
so  on  blocks.  But  the  many  details  involved  in  its  application 
will  be  better  learnt  by  three  months'  drcFsing  in  the  wards  than 
by  any  verbal  description.  In  children,  the  limb,  or  better  both 
limbs,  may  be  suspended  by  means  of  this  stirrup  in  a  vertical 
position  to  the  ceiUng  (Fig.  194),  the  weight  of  the  body  being 
the  counter-extending  force. 

3.  The  double-inclined  plane  is  very  useful  in  the  treatment  of 
fractures  of  the  upper  third  of  the  femur,  in  which  the  upper  frag- 
ment is  tilted  upwards  by  the  psoas  and 
ihacus,  and  cannot  be  kept  in  apposition 
with  the  lower.  By  means  of  the  double- 
incHned  plane  the  lower  fragment  is 
raised  and  brought  into  line  with  the 
upper,  extension  being  secured  by  the  leg 
and  foot  hanging  unsupported  down  the 
further  side  of  the  plane,  and  counter- 
extension  by  the  weight  of  the  body.  The 
plane  may  consist  of  an  ordinary  Mac- 
Intyre's  splint  bent  to  the  proper  angle,  or 
of  a  wooden  frame  that  can  be  adjusted  to 
the  proper  height  at  the  apex  where  the 
planes  meet.  Dr.  Hodgen's  and  Dr. 
Nathan  Smith's  sphnts  are  double-inclined 
planes  slung  on  pulleys,  but  space  does 
not  permit  of  them  being  described  here. 

4.  Plaster-of-Paris  and  starch  bandages 
are  employed  at  some  hospitals  from  the 
first,  and  the  patient  allowed  to  get  about 
on  crutches. 

III.  Fractures  through  the  lower  end  of  the  femur  very 
frequently  extend  either  transversely  or  obliquely  across  the  shaft, 
just  above  the  articular  surface,  and  vertically  or  obhquely  be- 
tween the  condyles  into  the  knee-joint,  the  broken  end  of  the 
shaft  being  often  impacted  between  the  partially-separated  con- 
dyles. Sometimes  the  line  of  fracture  may  be  entirely  supra- 
condyloid,  the  knee-joint  then  escaping.     In  young  subjects  the 


Fracture  of  the  femur  treated 
by  vertical  extension.  (Bry- 
ant's Surgery.) 


452  INJURIES   OF   REGIONS, 

fracture  may  occur  in  the  epiphysial  line  with  or  without  splinter- 
ing of  the  condyles.  Destructive  inflammation  of  the  knee-joint 
is  liable  to  follow  fractures  through  the  condyles,  but  is  certainly 
far  from  common. 

The  s/i^^/is,  when  the  fracture  is  supra-condyloid,  are  similar  to 
those  of  fracture  of  the  lower  third  of  the  shaft.  In  the  T-shaped 
fractine  in  which  the  knee  is  involved,  there  is  usually  great 
sweUing  of  the  joint  from  effusion  of  blood  and  serum  ;  increased 
width  of  the  femur  if  the  condyles  are  separated  from  each  other  : 
shortening  ;  inability  to  stand  on  or  use  the  limb ;  and  crepitus 
on  manipulation,  on  grasping  the  condyles,  and  often  on  moving 
the  patella  laterally.  In  fracture  through  the  epiphysis,  the  age 
of  the  patient,  and  the  soft  crepitus  characteristic  of  epiphysial 
fractures,  will  point  to  the  nature  of  the  injury.  The  separation 
of  the  fragments,  moreover,  is  usually  less  than  in  other  fractures 
in  this  situation,  as  the  two  surfaces  are  broad.  Union  generally 
occurs  by  bone,  hence  epiphysial  growth  is  arrested  and  shorten- 
ing is  common. 

Treatmoit. — Some  form  of  the  long  splint  may  be  applied  ;  or 
extension  made  by  the  stirrup,  weight,  and  pulley  ;  or  the  limb 
may  be  placed  on  an  iron  back-splint,  with  two  side  splints,  and 
slung  in  the  way  to  be  described  under  the  fracture  of  the  bones 
of  the  leg.  In  the  supra-condyloid  fracture,  where  the  lower 
fragment  is  much  tilted  backwards  by  the  gastrocnemius,  the 
tendo  Achillis  may  be  divided,  or  the  double  inclined  plane  used. 
In  any  case  an  ice-bag  or  lead  lotion  should  be  applied  to  the 
knee  till  the  effusion  is  absorbed.  Passive  movements  should  be 
begun  at  the  end  of  about  four  weeks. 

The  PArELLA. — Fractures  of  the  patella  are  most  common  in 
middle  life,  of  more  frequent  occurrence  in  men  than  in  women, 
and  very  rare  in  childhood.  Cause. — They  are  generally  due  to 
a  sudden  and  violent  action  of  the  quadriceps  extensor  muscle, 
such  as  is  exerted  by  a  person  to  regain  the  upright  position  when 
he  feels  himself  slipping  backwards,  the  knee  being  then  semi- 
flexed, and  the  patella  unsupported.  They  are  sometimes  caused 
■by  direct  violence,  as  a  blow  or  fall  upon  the  knee.  State  of  the 
parts. — When  due  to  muscular  action  the  line  of  the  fracture  is 
transverse  (Fig.  195),  the  aponeurotic  covering  is  usually  torn, 
and  the  upper  fragment  generally  drawn  some  distance  from  the 
lower  by  the  action  of  the  quadriceps  extensor.  When  due  to 
direct  violence  it  is  more  often  starred  or  vertical  (Fig.  196),  and 
the  aponeurosis  being  intact,  there  is  little  or  no  separation.  In 
any  case  the  fracture,  of  course,  extends  into  the  joint.  Method 
of  utiion. — When  the  fracture  is  transverse,  union  is  generally 
fibrous  or  membraneous,  rarely  osseous,  in  consequence  of  the 


THE    PATELLA. 


453 


fragments  being  separated,  probably  in  part  by  muscular  con- 
traction, and  in  part  by  the  effusion  of  blood,  and  later  of  serous 

Fig.  195. 


Fig.  197. 


Transverse  and  vertical  fracture  of  the  patella. 

fluid,  into  the  joint.  In  the  vertical  and  starred  fractures,  where 
the  parts  are  held  together  by  the  untorn  aponeurosis,  union  is 
usually  osseous.  Si's^ns. — At  first  a  gap  between  the  fragments 
can  be  seen  and  felt,  but  it  is  subsequently  obscured  by  swelling 
of  the  joint.  The  patient  cannot  stand,  or  extend  the  knee.  In 
a  vertical  fracture  crepitus  can  usually  be  detected,  and  the  frag- 
ments are  not  separated. 

Treatment. — If  seen  before  effusion  has  occuired,  the  whole 
limb  from  the  ankle  to  the  hip  should  be  enclosed  in  a  Bavarian 
plaster-of-Paris  splint,  and  the  pa- 
tient confined  to  bed  for  a  week, 
and  then  allowed  to  get  about  on 
crutches.  Even  when  effusion  has 
set  in,  this  plan  may  be  attended 
with  the  best  results.  Usually, 
however,  the  limb  is  placed  on  a 
back-splint  with  the  foot  raised  so 
as  to  relax  the  muscles  in  front  of 
the  thigh,  ice  or  cold  lotion  applied 

till  the  swelling  has  subsided,  and  then  an  endeavor  made  to  draw 
down  the  upper  fragment  as  nearly  as  may  be  into  contact  with 
the  lower.  Various  forms  of  apparatus  are  employed  for  this 
purpose,  amongst  which  may  be  mentioned  Manning's,  Ham- 
ilton's and  Steavenson's  splints,  INIalgaigne's  hooks  (Fig.  197), 
and  Mayo  Robson's  pins  (Fig.  199).  But  plaster-of-Paris  ap 
plied  in  the  way  above  described,  after  the  fragments  have  been 
as  much  as  possible  approximated  by  strips  of  strapping,  is  one 
of  the  best  methods  that  can  be  adopted.  On  the  removal  of 
whatever  apparatus  is  used  at  the  end  of  six  weeks  or  two  months, 
a  leathern  knee-cap,  to  prevent  flexion,  must  be  worn  from  three 
to  six  months,  and  subsequently  an  apparatus  to  partially  limit 


Malgaigne's  hooks,  with  key. 


454 


INJURIES    OF    REGIONS. 


flexion  for  two  or  three  years,  as  otherwise  there  is  a  great  ten- 
dency for  the  fibrous  material  uniting  the  fragments  to  become 
stretched,  and  the  fragments  to  become  widely  separated. 

Manning's  splint. — A  piece  of  webbing  is  taken  the  length  of 


Fig.  ig8. 


Fic.  199. 


Manning's  patella  splint.  The  leg  is  drawn  in  outline,  so  as  to  show  beneath  it  the  webbing 
band  passing  through  the  slit  in  the  splint.  The  strips  of  strapping  should  reach  up  the 
thigh  to  the  gluteal  fold. 

the  leg,  and  is  first  secured  to  the  back  of  the  thigh  by  a  dozen 
or  so  strips  of  strapping,  which  have  been  previously  sewn  to  the 
webbing,  the  lowest  strip  being  an  inch  or  two  from  the  patella. 
The  whole  limb  is  then  placed  on  a  back-splint  with  a  foot-piece, 

the  leg  and  foot  being  firmly  band- 
aged to  it  below,  and  the  thigh 
lightly  to  it  above.  The  free  end  of 
the  webbing  band  having  first  been 
brought  out  through  the  slit  in  the 
splint  midway  between  the  knee  and 
the  ankle  (see  Fig.  198),  is  now 
drawn  down  towards  the  foot-piece 
outside  the  splint,  and  sewn  over  a 
piece  of  stick,  which  is  secured  to 
the  foot-piece  by  an  india-rubber 
ring  (a)  on  each  side.  Thus  elastic 
tension  is  continually  exerted  upon 
the  upper  fragment,  and  so  draws  it 
down  towards  the  lower. 

Mayo  Kol> son's  Metliod. — A  strong 
steel  pin  is  passed  through  the  liga- 
mentum  patellae  outside  the  knee-joint ;  the  skin  is  then  drawn 
down  over  the  patella,  and  another  pin  passed  through  the  ten- 
don of  the  quadriceps  also  outside  the  joint.  The  two  pins  and 
with  them  the  fragments  of  the  patella  are  then  drawn  together 
by  a  figure-of-eight  suture  on  each  side,  so  as  to  bring  the  frac- 
tured surfaces  into  apposition.  An  antisei)tic  dressing  is  applied, 
and  the  pins  allowed  to  remain  ///  situ  for  a  month  (see  Fig.  199). 


Mayo   Robson's   method   of    holding 
fragments  of  patella  in  contact. 


THE    IIBIA    AND    FIBULA.  455 

Aspiration  of  the  joint.  Wiring  of  the  fragments . — With  the 
object  of  obtaining  firm  fibrous  or  bony  union,  some  Surgeons, 
where  there  is  much  distension  of  the  joint,  draw  off  the  blood  or 
serum  with  the  aspirator ;  and  others  lay  the  joint  freely  open  and 
wire  the  fragments  of  the  patella  together.  The  latter  proceed- 
ing, it  cannot  bfe  denied,  has  often  secured  bony  union  without 
any  ill  effects,  but  on  the  other  hand,  suppuration,  stiff-joint, 
amputation,  and  even  loss  of  life,  have  resulted.  In  the  face  of 
these  facts,  therefore,  and  considering  that  no  such  dangers  at- 
tend the  ordinary  methods,  and  that  by  these  methods  a  per- 
fectly useful  joint  can  be  obtained,  even  though  the  union  is  only 
fibrous,  I  have  hitherto  hesitated  to  undertake  such  an  operation 
for  a  recent  fracture  of  the  patella.  Recently  Mr.  Barker  has 
tied  the  fragments  together  subcutaneously  by  passing  a  suture  by 
the  aid  of  a  n^evus  needle  first  behind  the  patella,  and  then  in 
front  of  it  between  the  patella  and  the  skin.  The  blood  is 
squeezed  out  of  the  joint,  the  fragments  pressed  together,  and  the 
sutures  tied  tightly,  thus  keeping  the  fragments  in  apposition. 

The  tibia  and  fibula. — ^Both  bones,  or  the  tibia  or  fibula  alone, 
may  be  fractured. 

Fracture  of  both  bones,  which  is  by  far  the  most  common 
variety,  may  be  due  to  either  direct  or  indirect  violence.  When 
the  result  of  direct  violence,  the  fracture  occurs  at  the  spot  where 
the  force  is  applied,  and  both  bones  are  usually  fractured  more 
or  less  transversely,  and  in  the  same  line  ;  but  when  the  result  of 
indirect  violence,  the  tibia  generally  first  gives  way  at  its  weakest 
spot,  /.  e.,  about  the  junction  of  the  middle  with  the  lower  third, 
and  then  the  fibula  also  at  its  weakest  spot,  i.  e.,  in  its  ripper 
third,  and  the  fractures  are  usually  oblique.  In  the  transverse 
fracture  but_  little  displacement  occurs ;  in  the  oblique,  in  which 
the  Hne  of  fracture  usually  runs  downwards,  forwards,  and  a  little 
inwards,  the  lower  fragments  are  drawn  upwards,  backwards  and 
outwards,  behind  the  upper,  by  the  muscles  of  the  calf,  while  the 
sharp  end  of  the  upper  fragment  of  the  tibia  projects  forwards, 
threatening,  and  indeed  often  causing,  perforation  of  the  skin 
(Fig.  200). 

Fracture  of  the  tibia  alone  is  generally  caused  by  direct  violence, 
as  a  kick  or  a  blow  on  the  shin,  occasionally  by  indirect  violence, 
as  a  fall  on  the  foot.  Nature  of  the  displacement. — The  fracture 
is  usually  situated  in  the  lower  third  of  the  bone,  and  is  generally 
transverse,  and  attended  by  Httle  displacement,  the  fragments 
being  held  in  position  by  the  fibula,  which  plays  the  part  of  a 
splint.  Fractures  of  the  upper  and  lower  ends,  involving  the 
knee-  and  ankle-joints  respectively,  and  separation  of  the  upper 
and  lower  epiphysis,  may  also  occur,  but  are  rare. 


456 


INJURIES   OF   REGIONS. 


Fig. 


Fracture  of  the  fibula  alone  is  more  common  than  fracture  of 
the  tibia  alone.  Cause. — Though  sometimes  produced  by  direct 
it  is  more  often  the  result  of  indirect  violence,  such  as  a  severe 
wrench  or  twist  of  the  foot.  The  fracture  is  then  generally  situ- 
ated from  two  to  three  inches  from  the  external  malleolus,  and 
the  foot  is  at  the  same  time  very  commonly  dislocated  either  out- 
wards or  inwards,  according  to  the  direction  of  the  force.  Nature 
of  the  displacement. — In  the  fracture  with 
outward  dislocation  of  the  foot  {Pottos 
fracture,  as  it  is  generally  called),  the 
upper  end  of  the  lower  fragment  is  driven 
inwards  towards  the  tibia,  the  external 
lateral  ligament  remains  intact,  but  the  in- 
ternal lateral  ligament  is  ruptured,  or  the 
end  of  the  internal  malleolus  is  torn  off. 
The  foot,  at  the  same  time  that  it  is  dis- 
placed outwards,  is  also  drawn  backwards 
by  the  tendo  Achillis.  In  the  fracture 
with  inward  dislocation  (which  is  rare), 
the  articular  surface  of  the  external  mal- 
leolus usually  follows  the  astragalus,  and 
the  upper  end  of  the  lower  fragment  of 
the  fibula  in  consequence  projects  out- 
wards. 

Signs. — In  fracture  of  both  bones  the 
signs  are  usually  unmistakable,  especially 
when  the  fracture  is  oblique  and  in  the 
lower  third  of  the  leg.  When  the  tibia  or 
fibula  alone  is  fractured  the  diagnosis  is 
often  very  difficult.  In  the  tibia  some 
irregularity  may  be  felt  oh  running  the 
finger  along  the  shin,  and  crepitus  may  perhaps  be  elicited.  In 
the  fibula,  fracture  of  the  lower  third  may  be  detected  by  running 
the  finger  along  the  subcutaneous  surface  of  the  bone  just  above 
the  external  malleolus ;  but  if  the  case  is  not  seen  till  swelling 
from  effusion  has  set  in,  it  may  be  quite  impossible  to  say  whether 
we  are  dealing  with  a  fracture  or  a  sprain.  If  in  doubt  the  case 
should  be  treated  as  a  fracture.  In  the  upper  two-thirds,  where 
the  bone  is  covered  with  muscles,  and  cannot  be  felt,  the  follow- 
ing tests  for  fracture  may  lie  applied  :  i.  Move  the  foot  laterally, 
and  crepitus  will  probably  be  elicited  if  there  is  a  fracture.  2. 
Press  the  tibia  and  fibula  together  just  above  the  ankle  by  grasp- 
ing them  with  the  hand.  In  fracture,  pain  will  be  felt  at  the  frac- 
tured spot,  not  at  the  situation  where  grasped.  3.  Grasp  the 
tibia  and  fibula  with  the  hands  just  below  the  knee  and  above  the 


Fracture  of  the  lower  third  of 
the  tibia.     (After  (Jray.) 


FRACTURE   OF   THE   FIBULA. 


457 


Fig.  20I. 


ankle.  If  there  is  a  fracture  the  natural  springiness  of  the  fibula 
will  be  lost,  and  crepitus  may  perhaps  be  detected.  In  Pott's 
fractu7'e  (Fig.  201),  the  foot  is  twisted  outwards,  so  that  whilst 
the  inner  edge  is  towards  the  ground  the  sole  is  directed  out- 
wards. There  is  a  well-marked  depression  over  the  seat  of  frac- 
ture, the  internal  malleolus  projects  prominently  under  the  skin, 
and  crepitus  can  be  easily  obtained.  There  is  also  marked  back- 
ward displacement  of  the  foot. 

Treatment. — In  uncomplicated  fractures  of  the  tibia  or  fibula 
alone,  the  leg  may  be  placed  at  once  in 
plaster-of-Paris  splints,  and  the  patient, 
after  a  {^^^  days'  rest  in  bed,  allowed  to 
get  about  on  crutches.  Where  there  is 
much  swelling,  the  leg  had  better  be  placed 
for  a  few  days  on  a  back- splint  to  allow 
the  swelling  to  subside  before  the  plaster- 
of-Paris  is  applied.  In  simple  fracture  of 
both  bones,  where  the  line  of  fracture  is 
transverse  and  there  is  but  little  swelling  or 
displacement,  the  same  treatment  may 
often  be  adopted  with  advantage.  But 
greater  care  and  watchfulness  will  be 
necessary  to  prevent  any  untoward  acci- 
dent. Indeed,  whenever  this  method  of 
treating  fractures  is  used,  the  precautions 
mentioned  at  page  174  should  be  taken. 
When  there  is  any  displacement,  however, 
the  fracture  must  be  reduced  by  making 
traction  upon  the  foot  whilst  the  thigh  is  steadied  by  an  assistant, 
special  care  being  taken  to  correct  the  eversion,  so  frequently  pres- 
ent, of  the  lower  fragment.  You  will  know  when  this  has  been  done 
by  the  inner  side  of  the  patella,  the  internal  malleolus,  and  the 
inner  side  of  the  great  toe  being  in  the  same  line.  Further,  you 
should  not,  as  a  rule,  rest  satisfied  as  long  as  any  irregularity  can 
be  felt  on  drawing  your  finger  down  the  crest  of  the  tibia,  or  as 
long  as  any  marked  difference  is  apparent  on  comparing  the  frac- 
tured with  the  sound  leg.  If  any  difficulty  is  experienced,  give 
chloroform,  and  if  necessary,  cut  the  tendo  Achillis.  Having  re- 
duced the  fracture,  secure  the  foot  and  leg  on  a  splint.  What- 
ever form  of  the  various  splints  for  the  purpose  is  adopted,  take 
care  : — i,  that  the  foot  is  at  right  angles  to  the  leg;  2,  that  the 
ball  of  the  toes  and  the  heel  touch  the  foot-piece  of  the  splint ; 
3,  that  the  foot  is  square  with  the  foot-piece  ;  and  4,  that  the  back 
of  the  heel  is  kept  from  contact  with  the  splint  by  a  small  pad 
placed  under  the  tendo  Achillis  just  above  the  heel.  The  iron 
20 


Pott's  fracture.  (St.  Bar- 
tholomew's Hospital  Mu- 
seum.) 


458 


INJURIES   OF   REGIONS. 


splint  and  cradle,  shown  in  Fig.  202,  is  almost  invariably  em- 
ployed by  the  whole  of  the  surgical  staff  at  St.  Bartholomew's 
Hospital  for  ordinary  fractures  of  the  tibia  and  fibula,  and  with 
the  most  satisfactory  results.  In  applying  the  splint,  which  should 
reach  as  high  as  the  junction  of  the  middle  with  the  lower  third 
of  the  thigh,  and  should  be  well  padded  and  shaped  to  the  limb, 
the  foot  is  first  secured  to  the  foot-piece  by  strapping  and  a  band- 

FiG.  202. 


Fracture  apparatus  for  the  bones  of  leg. 

age.  The  Surgeon  having  then  assured  himself  that  the  fracture 
is  in  good  position,  secures  the  splint  by  a  broad  strip  of  strap- 
ping, and  a  figure-of-eight  bandage  over  the  knee.  The  splint  is 
next  swung  in  the  cradle,  as  shown  in  the  figure,  and  side  splints 


Fig.  203. 


C'line's  splints  (or  I'ott's  fr.-ictiirc.      The  outside  splint  is  known  by  the  foot-piece. 

are  then  applied  and  fixed  by  webbing  straps.  In  the  case  of 
fracture  of  both  bones,  the  apparatus  is  generally  kept  on  for  a 
month  ;  in  the  case  of  the  fibula  or  tibia  alone,  for  two  or  three 
weeks.  The  leg  is  then  placed  in  a  plaster  of- Paris,  a  gum  and 
chalk,  or  a  silicate  of  .soda  bandage.  In  Pott's  fracture,  the 
above  apparatus  is  also  generally  used,  and  here  again  I  speak  of 


POTT  S    FRACTURE. 


459 


Roughton's  splint. 


it  in  the  highest  praise.  Where,  however,  there  is  much  difficulty 
in  keeping  the  bones  in  good  position,  the  leg  is  sometimes  laid 
on  its  outer  side,  with  the  knee  semi-flexed  to  relax  the  gas- 
trocnemius, and  secured  in  Cline's  splints  (Fig.  203),  the  tendo 
Achillis  being  divided,  if  found  necessary.  The  backward  dis- 
placement of  the  heel, 
Fig.  204.  however,  is  best  corrected 

by  using  Roughton's  mod- 
ification of  the  splint  (Fig. 
204).      It  consists  of  an 
outside  splint  with  a  foot- 
piece.     The  heel  is  drawn 
forward    and    secured    in 
position  by  a  "  heel  band- 
age," the  limb  being  fixed 
to   the  splint  by  two  other  bandages,  one  placed  just  above  the 
ankle  and  the  other  just  below  the  knee  (Fig,  205).     At  times 
Dupuytren's  splint  (Fig.  206)   may  be  better  adapted   to  a  par- 
ticular case.     The  splint  con- 
FiG.  205.  sists  of  a  straight  lath  notched 

at  its  lower  end.  It  is  placed 
on  the  inner  side  of  the  limb, 
and  should  reach  from  the 
tuberosity  of  the  tibia  to  three 
or  four  inches  below  the  foot. 
A  wedge-shaped  pad,  with  its 
base  below,  and  not  extending 
beyond  the  internal  malleolus, 
should  line  the  splint.  The 
splint  is  bandaged  on  from 
above  downwards,  and  the  leg 
having  been  thus  secured,  the 
foot  is  brought  over  to  the  splint  by  making  figure-of-eight  turns 
over  the  ankle  and  foot  and  through  the  notches  at  the  lower  end 
of  the  splint.     The  bandage  should  not  pass  over  the  external 


•*&.! 


Roughton's  splint  applied.     The  arrows  show 
the  direction  in  which  the  bandages  pull. 


Fig.  206. 


Dupuytren'":  splint  for  Pott's  fracture. 

malleolus  or  the  seat  of  fracture.  The  great  objection  to  the  use 
of  this  splint  is,  that  having  no  foot-piece,  the  foot  is  not  kept  at 
a  right  angle  to  the  leg.  When  no  special  apparatus  is  at  hand 
the   fracture,  whether  of  both  bones  of  the  leg  or  of  one  bone 


460 


INJURIES   OF    REGIONS. 


only,  may  be  put  up  in  what  is  known  in  Edinburgh  as  the  box- 
splint  (Figs.  207,  208).  All  that  is  required  is  two  ordinary  side 
splints  and  some  towels,  cotton  wool,  and  a  few  bandages.  The 
spHnts  showld  be  rolled  in  the  two  ends  of  a  long  towel  (Fig. 
207)  so  as  to  form  a  trough  for  the  fracture,  the  width  of  the 
trough  being  determined  by  first  placing  the  sound  leg  in  it.  The 
fracture  having  been  set,  the  leg  is  placed  on  the  towel  and  the 
splints  forming  the  sides  of  the  trough  or  box  are  raised  and  se- 
cured in  position  by  slip-knot  bandages  (Fig.  208).  Pads  formed 
of  folded  towels  should  be  placed  over  the  tibia  or  where  re- 
quired, and  the  foot  fixed  at  a  right  angle  to  the  leg  by  a  figure- 
of-eight  bandage  (Fig.  208).  Backward  displacement  of  the 
heel  may  be  controlled  by  a  ring-pad. 

The  tarsus. — Fractures  of  the  bones  of  the  tarsus  are  for  the 


Fig.  207. 


The  Pox-splint  for  fracture  of  the  Ijones  of  the  leg.  In  the  ujjpcr  fig\irc  the  position  of  a 
towel  used  as  a  pad  is  shown.  In  the  lower  figure  ihc  :ii)i)ai:itiis  is  shown  completed. 
(After  Caud  and  Cathcart.) 

most  part  the  result  of  great  violence,  and  are  rare.  The  only 
one  calling  for  y^assing  notice  is  fi-actiirc  of  ihc  os  calcis,  which 
may  occur  from  a  fall  on  the  heel,  passage  of  a  wheel  over  the 
foot,  or  violent  contraction  of  the  calf-muscles.  Crej)itus,  and, 
when  the  line  of  fracture  is  behind  the  interosseous  ligament, 
some  drawing  up  of  the  posterior  fragment  by  the  tendo  Achillis, 
are  the  chief  signs,  iiut  where  there  is  much  swelling  and  bruis- 
ing of  the  soft  parts,  the  fracture,  as  is  the  case  in  fractures  of  the 


THE  METATARSAL  BONES  AND  PHALANGES.         46 1 

astragalus  and  of  the  other  tarsal  bones,  may  be  very  difficult  to 
diagnose.  Rest,  with  the  foot  and  leg  on  a  splint,  in  such  a  posi- 
tion as  to  relax  the  calf  muscles  where  there  is  much  displace- 
ment, and  an  ice-bag  to  subdue  inflammation,  are  the  points  to 
be  attended  to  with  regard  to  treatment.  When  the  case  is  seen 
early,  and  there  is  but  little  swelling,  a  plaster-of-Paris  splint  or 
bandage  may  be  advantageously  used. 

The  metatarsal  bones  and  phalanges  of  the  toes  may  be  frac- 
tured by  direct  violence.  No  special  description,  however,  of 
these  fractures  is  necessary. 


462  DISEASES   OF    REGIONS. 


SECTION  VI. 

Diseases  of  Regions. 

diseases  of  the  scalp  and  skull, 

Erysipelas  of  the  scalp  is  common,  and  may  occur  idiopath- 
ically,  or  as  the  result  of  a  wound.  In  the  so-called  idiopathic 
cases,  however,  it  is  probable  that  there  is  generally  some  scratch 
or  abrasion  through  which  the  specific  micrococcus  gains  admis- 
sion. The  inflammation  spreads  with  great  rapidity,  but  is  accom- 
panied by  very  little  redness  and  swelling,  on  account  of  the 
tenseness  of  the  parts.  It  is  apt  to  be  attended  with  headache, 
drowsiness,  or  deliriiim,  consequent  upon  the  hypersemia  extend- 
ing to  the  pia  mater.     See  Erysipelas,  p.  144. 

Cellulitis  of  the  scalp  is  usually  due  to  a  wound,  and  is 
described  under  Injuries  of  the  Scalp.     {See  also  Celluhtis.) 

Abscess  may  occur  above  the  aponeurosis,  between  the  aponeu- 
rosis and  the  pericranium,  or  beneath  the  pericranium.  It  is  gen- 
erally the  result  of  an  injury,  but  may  be  due  to  the  breaking 
down  of  a  gumma,  diseases  of  the  bones,  etc.  It  is  further  re- 
ferred to  under  Injuries  of  the  Head  (p.  327). 

Rodent  ulcer,  and  Epithelioma  of  the  scalp,  require  no 
special  mention  here. 

Sebaceous  cysts  are  very  common  on  the  scalp,  where  they  are 
at  times  hereditary.  They  are  frequently  multiple,  and  as  they 
increase  in  size,  the  hair  covering  them  falls  off,  and  they  appear 
as  bare,  rounded  tumors.  The  signs,  secondary  changes, 
diagnosis,  and  treatment  of  these  cysts  have  been  given  at  p.  99. 
All  that  need  here  be  repeated  is  that  the  mass  of  granulations 
which  sometimes  protrudes  from  the  walls  of  these  cysts  {fi/ni^atiii(^ 
ulcer  of  the  sea /p)  closely  resembles  ei)ithelioma,  from  which,  how- 
ever, it  may  generally  be  distinguished  by  the  absence  of  indura- 
tion and  glandular  enlargement,  and  by  the  history  of  a  sebaceous 
cyst  having  been  j)reviously  present.  Congenital  and  dermoid 
cysts  are  described  at  p.  102. 

N^vi  are  also  common  on  the  scalp.  When  large  and  situated 
over  the  anterior  fontanelle  they  should  be  dealt  with  cautiously, 
lest  the  membranes  of  the  brain  be  injured  and  meningitis  result. 

Caries  and  necrosis  of  the  bones  of  the  cranium  are  not  un- 
common.    'J'hey  are  generally  the  result  of  syphilitic  periostitis  or 


MENINGOCELE    AND    ENCEPHALOCELE.  463 

injury,  or  very  rarely  of  tubercle  or  fevers.  The  external  table  is 
the  most  often  affected,  but  whether  the  external  or  the  internal 
table  is  involved,  the  disease  seldom  extends  beyond  the  diploe,  as 
the  two  tables  have  a  distinct  blood-supply.  At  times,  however, 
complete  perforation  of  the  skull  occurs.  Caries  and  necrosis  in 
this  situation  are  apt  to  be  followed  by  septic  or  infective  inflam- 
mation of  the  diploe  and  its  consequences  ;  by  suppuration  between 
the  bone  and  dura  mater  ;  by  meningitis  and  abscess  of  the  brain  ; 
or  by  thickening  of  the  dura  mater,  resulting  in  persistent  head- 
ache or  even  epilepsy.  When  the  skull  is  completely  perforated, 
the  hole  is  not  filled  up  by  bone  ;  and  when  necrosis  occurs  the 
sequestrum  is  not  invaginated.  Treatmerti. — Beyond  keeping  the 
parts  aseptic,  providing  free  exit  for  the  discharges,  and  removing 
loose  sequestra,  little,  as  a  rule,  is  required.  Should  pus  collect 
between  the  bone  and  dura  mater,  it  must  be  let  out  by  the  tre- 
phine ;  and  a  portion  of  necrosed  inner  table  may  also  require  the 
trephine  for  its  removal.  Appropriate  constitutional  remedies  for 
syphilis  or  tubercle  will  of  course  also  be  necessary. 

ExoTOSES  of  the  skull  are  described  under  Diseases  of  Eone, 
p.  230. 

Meningocele  and  Encephalocele  are  rare  congenital  tumors, 
formed  by  a  protusion  of  the  membranes  of  the  brain  through  an 
unossified  part  of  the  skull.  They  are  believed  to  be  dependent 
upon  hydrocephalus,  the  excess  of  fluid  in  the  sub-arachnoid  space 
or  in  the  ventricles  of  the  brain  leading  respectively  to  a  protrusion 
of  the  membranes  alone  {meningocele),  or  of  the  brain  also  {en- 
cephalocele). In  the  latter  instance,  the  dilated  ventricle  may  ex- 
tend into  the  protruding  portion  of  the  brain,  a  condition  further 
distinguished  as  hydrencephalocele.  The  protrusion  is  most  common 
in  the  occipital  region,  just  behind  the  foramen  magnum,  be- 
tween the  four  centres  from  which  this  part  of  the  occipital  bone 
is  ossified ;  next,  at  the  root  of  the  nose,  between  the  frontal  and 
nasal  bones ;  but  it  may  occur  in  any  situation  in  the  course  of 
the  sutures,  and  even  project  into  the  nasal  fossae  or  pharynx. 
Symptoms. — In  the  occipital  region  these  tumors  are  generally 
pedunculated  and  of  large  size — sometimes  nearly  as  large  as  the 
child's  head ;  at  the  root  of  the  nose  they  are  usually  small  and 
sessile.  The  skin  covering  them  is  generally  normal.  They  swell 
up  when  the  child  cries,  and  can  be  completely  or  partially  re- 
duced on  pressure,  the  reduction  sometimes  producing  convul- 
sions or  other  brain  symptoms.  When  they  contain  fluid  only 
{meningocele)  they  are  soft,  fluctuating,  translucent,  and  com- 
pletely reducible  on  pressure  ;  they  rarely  pulsate,  and  are  gen- 
erally pedunculated.  When  they  contain  brain- matter  {encepha- 
locele)  they  are  doughy,  non-fluctuating,  opaque,  and  only  par- 


464  DISEASES   OF   REGIONS. 

tially  reducible  ;  they  pulsate,  and  are  usually  sessile.  They  may 
be  mistaken  for  other  tumors  of  the  scalp,  but  especially  for  con- 
genital dermoid  cysts  and  degenerate  n^vi.  However,  their  in- 
tmiate  connection  with  the  bone,  their  situation  in  the  course  of 
the  sutures,  and  their  partial  or  complete  reducibility,  together 
with  the  facts  that  they  swell  up  on  expiratory  efforts,  and  occasion- 
ally pulsate  synchronously  with  the  brain,  will  usually  serve  for 
their  diagnosis.  Further,  the  hole  in  the  skull  may  at  times  be 
detected  and  brain  symptoms  be  produced  by  pressure.  Treat- 
ment.— As  a  rule  they  should  be  left  alone,  or  merely  supported 
by  a  pad  or  bandage.  A  meningocele,  when  pedunculated,  and 
apparently  communicating  with  the  interior  of  the  cranium  by  a 
small  aperture  only,  may  be  injecled  with  Morton's  fluid,  or  under 
exceptional  circumstances  excised. 

Fungous  Tumors,  generally  of  a  sarcomatous  nature,  and 
springing  either  from  the  tissues  of  the  scalp  or  pericranium,  or 
from  the  diploe  or  dura  mater  and  then  penetrating  the  bone,  are 
occasionally  met  with,  and  may  be  mistaken  for  inflammatory 
affections  of  the  pericranium  or  bone,  or  for  syphilitic  gummata. 
Their  rapid  growth,  resistance  to  syphilitic  remedies,  the  escape 
of  blood  only  on  puncture,  and  the  concomitant  loss  of  weight 
and  strength  of  the  patient,  will  usually  serve  to  distinguish  them  ; 
but  an  exploratory  incision  may  in  some  cases  be  necessary  to 
clear  up  the  diagnosis.  Secondary  tumors  which  pulsate  and  have 
the  structure  of  thyroid-gland  tissue,  are  also  very  occasionally 
met  with  in  cases  of  malignant  goitre.  Treatinetil. — Where  there 
is  no  evidence  of  dissemination,  and  the  tumor  is  small  and  fairly 
circumscribed,  it  may  be  removed.  When  growing  from  the 
scalp  this  can  usually  be  done  without  much  difficulty ;  but  when 
the  growth  arises  from  the  bone  or  dura  mater  a  much  more 
serious  operation  will  of  course  be  required,  since  a  considerable 
portion  of  the  skull  will  have  to  be  cut  away,  and  the  dura  mater 
probably  opened.  It  need  hardly  be  said  that  the  strictest  anti- 
septic precautions  must  be  observed. 

DISEASES    OF    THE    BRAIN    THAT    MAY    CALL    FOR    SURGICAL 
INTERFERENCE. 

Abscess  in  the  brain  is  generally  the  result  of  a  head-injury  or 
of  middle-ear  disease,  and  when  its  situation  can  be  localized 
with  a  fair  amount  of  probability  imperatively  calls  for  surgical 
interference.  See  Intracranial  Su]jpuration  and  Complications  of 
Middlc-I'^ar  Disease. 

The  'i  umors  and  new  growths  in  the  brain  suitable  for  opera- 
tion are  gliomata  and  psammomata,  localized  tubercular  lesions, 


THE   TUMORS. 


465 


syphilitic  scars  which  drugs  cannot  absorb,  scar-tissue  and  cystic 
formations  following  injury,  and  parasitic  cysts.  Sarcomatous  and 
carcinomatous  growths  are  usually  too  extensive  for  removal,  or 
are  multiple  from  the  first.  Moreover  since  they  have  no  capsule 
they  are  not  sufficiently  distinguishable  from  the  surrounding  brain 
substance  to  ensure  their  complete  excision  and  their  non-return 
in  the  scar.  The  chief  signs  of  a  cerebral  tumor  are  vomiting, 
persistent  headache,  optic  neuritis,  localized  spasms  or  paralysis, 
and  epileptiform  convulsions,  the  convulsive  seizures  usually  start- 
ing in  the  part  connected  with  the  cortical  area  involved  in  the 
growth  {Jacksonian  Epilepsy).  Among  the  symptoms  that  may 
enable  the  Surgeon  to  localize  the  growth  are  the  following  (Figs. 
209  and  210)  : — i.  If  at  the  beginning  of  the  epileptiform  fit 


Fig.  209. 


The  convolutions  of  the  outer  surface  of  the  left  cerebral  hemisphere  with  the  cortical  centres 
marked.  F,,  f„,  F3,  First,  second,  and  third  frontal  convolutions;  t,,  t.,,  t^,  First, 
second,  and  third  temporosphcnoidal  convolution^;  A.  Angul.nr  convolution ;  o.  Occipital 
lobe;   F  s.  Sylvian  fissure;  p  o  F.  Pa rieto-occipital  fissure;   p  F.  Intra-parietal  fissure. 

there  is — {a)  pain,  peculiar  sensation,  flexion,  or  hyper-extension 
of  the  great  toe,  a  lesion  of  the  leg-area  on  the  opposite  side  of 
the  cortex  about  the  upper  end  of  the  fissure  of  Rolando  close  to 
the  middle  line  is  indicated  ;  {b)  movements  of  the  shoulder,  a 
lesion  near  the  upper  part  and  rather  in  front  of  the  fissure  ;  {/) 
flexion  of  the  thumb,  a  lesion  about  the  genu  of  the  fissure  ;  (^) 
turning  of  the  head  and  eyes  to  the  opposite  side,  a  lesion  about 


466  DISEASES   OF   REGIONS. 

the  hinder  portion  of  the  superior  and  middle  frontal  convolu- 
tions ;  (e)  movements  of  the  mouth  and  tongue,  a  lesion  about 
the  lower  end  of  the  fissure  of  Rolando.  An  epileptiform  move- 
ment starting  in  one  of  these  parts  may  be  followed  by  loss  of 
power  in  the  part  for  some  time  after  the  fit.  2.  Aphasia  indi- 
cates a  lesion  of  Broca's  convolution.  3.  Loss  of  half  the  fields 
of  vision  in  both  eyes  points  to  a  lesion  of  the  angular  gyrus  of 
the  side  opposite  to  the  lost  fields  of  vision.  4.  Loss  of  hearing 
suggests  a  lesion  of  the  two  upper  temporosphenoidal  lobes.  5. 
The  aid  to  localization  that  may  be  derived  from  the  involvement 

Fig.  210. 


The  convolutions  of  the  median  surface  of  the  left  cerebral  hemisphere  with  the  cortical  centres 
marked.  F,,  First  frontal  convolution:  c  in  i".  Calloso-marginal  fissure;  r,  f.  Gyrus  forni- 
catus;  Q.  Quadrate  lobule;  c.  Cuneate  lobule;  p  o  i",  Parieto-occipilal  fissure;  c  f.  Cal- 
carine  fissure;   v.  Uncinate  lobule;   v.  Paracentral  lobule. 

of  the  cranial  nerves  has  already  been  mentioned  under  Injuries 
of  the  Head  (p.  342). 

Where,  from  a  consideration  of  the  above  symptoms,  a  tumor 
or  new  growth  is  believed  to  be  fairly  circumscribed  and  in  an 
accessible  situation,  the  skull  should  be  trephined,  a  sufficient 
portion  of  the  bone  removed  to  fully  expose  the  growth,  by  a 
Hey's  saw,  Hoffmann's  or  Keen's  forceps,  or  the  surgical  engine, 
and  the  growth  cut  away  by  making  perpendicular  incisions  into 
the  brain  around  it  and  raising  it  by  means  of  a  sharp  spoon. 
The  removal  of  a  portion  of  the  cortex  will  be  followed  by  loss  of 
function  of  the  area  removed,  but  this  to  a  great  extent  will  be 
regained  by  the  aid  of  the  surrounding  areas,  especially  as  regards 
the  coarser  movements.  "^I'he  finer  movements  of  the  fingers  and 
thumb  will  not  be  completely  regained  ;  hence  in  this  region  the 
removal  of  cortex  should  be  as  limited  as  is  consistent  with  suc- 
cess.    Parasitic  cysts  should  be  drained.     See  Trephining,  p.  347. 


CRANIECTOMY.  467 

Focal  epilepsy,  general  paralysis,  cephalalgia.  In  focal  epi- 
lepsy, that  is  epilepsy  without  obvious  gross  lesion,  when  the  fits 
become  very  frequent,  for  example  more  than  one  an  hour,  and 
the  mental  processes  are  becoming  further  impaired,  the  focus  in 
the  cortex  representing  the  initial  movements  may  be  exposed, 
the  exact  spot  for  the  initial  movements  found  by  exciting  the 
brain  with  the  Faradic  current,  and  this  area  of  the  cortex  ex- 
cised. After  such  an  operation  a  diminution  in  the  number  of  fits 
as  well  as  an  improvement  in  the  health  of  the  patient  may  be 
expected.  In  general  paralysis  trephining  in  a  few  cases  has  been 
of  some  benefit  in  the  early  stages  of  the  disease.  Thus  the  hal- 
lucinations have  disappeared  and  the  patient  has  so  far  improved 
as  to  be  fit  to  be  at  liberty.  In  severe  cephalalgia  incapacitating 
the  patient  for  work  or  preventing  sleep,  trephining  may  give  re- 
lief. In  such  cases  an  exostosis,  a  spiculum  of  bone,  an  enlarged 
Pacchionian  body,  or  a  fibrous  tumor  or  cyst  of  the  dura  mater 
has  been  found,  and  its  removal  has  been  foUovved  by  complete 
recovery.  In  other  cases  where  a  tumor,  etc.,  of  the  brain  which 
did  not  permit  of  removal  has  been  discovered,  the  relief  of  pres- 
sure has  freed 'the  patient  from  the  excessive  pain,  or  threatened 
blindness. 

Hydrocephalus,  especially  {a')  when  accompanied  by  fits,  (b^ 
when  progressive  atrophy  of  the  optic  nerve  threatens,  or  {c)  when 
dementia  or  coma  supervenes,  may  be  treated  by  tapping  the 
ventricles  at  intervals  and  applying  sHght  pressure  to  the  skull,  or 
if  this  fails,  by  continuous  drainage  of  the  ventricles. 

Microcephaly  combined  with  idiocy,  due  it  is  thought  to  too 
early  synostosis  of  the  cranial  sutures,  especially  the  sagittal  and 
coronal,  may  be  benefited  by  craniectomy,  /.  e.,  the  removal  of  a 
strip  of  bone  on  either  side  of  the  middle  line  of  the  skull.  The 
aim  of  the  operation  is  to  allow  the  brain,  the  development  of 
which  has  been  prevented  by  the  early  synostosis,  to  expand.  In 
some  of  the  cases  reported  the  mind  of  the  child  had  continued 
to  develop  since  the  operation. 

Craniectomy. — Having  prepared  the  scalp  as  described  under 
trephining  (p.  347),  make  a  semicircular  incision  over  the  side  of 
the  head,  extending  from  a  little  behind  the  external  angular  pro- 
cess of  the  frontal  bone  to  a  little  in  front  of  the  middle  of  the 
lambdoid  suture ;  turn  down  the  large  semicircular  flap  thus 
marked  out,  and  apply  a  half-inch  trephine  over  the  parietal  bone 
two  inches  or  so  external  to  the  sagittal  suture.  Gently  separate 
the  dura  mater  and  cut  away  with  Hoffmann's  or  Keen's  forceps 
a  narrow  strip  of  bone  some  five  or  six  inches  long  from  the  pari- 
etal and  frontal  bones,  parallel  to  the  sagittal  and  interfrontal 
sutures.     Care  should  be  taken  during  the  operation  to  make  as 


468 


DISEASES   OF   REGIONS. 


little  pressure  as  possible  on  the  brain.  At  the  end  of  the  opera- 
tion the  flap  should  be  replaced  and  accurately  secured  by  sutures. 
The  operation  should  be  repeated  on  the  opposite  side  of  the 
head  when  the  first  wound  has  healed.  I  have  performed  this 
operation  on  three  patients,  but  sufficient  time  has  not  elapsed  to 
say  what  improvement  in  their  mental  condition  will  result. 

The  strictest  antiseptic  precautions  in  this  as  in  all  operations 
on  the  skull  and  brain  should  of  course  be  taken.  See  Trephin- 
ing, P-  347- 

DISEASES    OF   THE    EAR. 

By  A.  E.  CuMBERBATCH,  F.  R.  C.  S.,  Aural  Surgeon  to 
St.  Bartholomew's  Hospital. 

Physical  examination  of  the  ear. — In  making  an  examina- 
tion of  a  patient,  let  him  be  seated  between  the  Surgeon  and  the 
source  of  light,  with  the  affected  ear  towards  the  examiner. 
Throw  the  light  on  the  ear  with  the  mirror  and  notice  any  ab- 
normal condition  of  the  auricle  or  the  external  meatus.  Next 
grasp  the  auricle  between  the  middle  and  index  fingers,  the 
speculum  (Fig.  211)  between  the  index  finger  and  thumb,  and 
pulling  the  auricle  upwards  and  backwards  insert  the  speculum 


Fig.  211. 


Fig.  212. 


Aural  specula. 


Aural  toothed  forceps. 


with  a  gentle  rotatory  movement.  Any  epithelium  or  wax  that 
may  obstruct  the  view  should  be  removed  by  means  of  forceps 
(Fig.  212)  or  the  syringe.  If  the  canal  be  unobstructed,  the 
membrana  tympani  can  be  seen  stretching  across  its  deeper  part 
as  a  delicate  bluish-grey  or  yellowish-grey  semi-transparent  and 
highly  polished  film.  Near  the  upper  and  anterior  margin  is  a 
whitish  prominence — the  processus  brcvis,  and  running  down- 
wards and  boackvvards  from  this,  to  a  point  just  below  the  centre 
of  the  membrane,  is  the  handle  of  the  malleus.  From  the  tip  of 
the  handle  a  cone  of  light  extends  downwards  and  forwards,  with 
its  base  to  the  perij^hcry.      I''rom  the  ])rocessus  brevis  two  indis- 


PHYSICAL   EXAMINATION   OF   THE   EAR.  469 

tinct  lines  extend  backwards  and  forwards — the  anterior  and 
posterior  folds.  If  the  membrane  be  very  thin  or  its  posterior 
segment  much  retracted,  the  long  process  of  the  incus  can  be 
seen,  posterior  to  and  parallel  with  the  handle  of  the  malleus. 
The  portion  of  membrane  above  the  anterior  and  posterior  folds 
is  called  SchrapnelPs  memb?-ane,  and  consists  only  of  the  dermoid 
and  mucous  layers.  Whilst  noting  these  points,  carefully  search 
the  membrane  for  perforations,  opacities,  or  small  polypi.  After 
thus  inspecting  the  membrane,  its  mobiHty  should  be  ascertained 
by  means  of  i,  the  pneumatic  speculum,  or  2,  by  forcing  air  into 
the  tympanum  through  the  Eustachian  tube,  either  by  {a) 
Valsalva's  method,  (l>)  by  Pohtzer's  method,  or  {c)  by  the 
catheter. 

{a)  Valsalva's  method  consists  in  making  forcible  expiration 
with  the  nose  and  mouth  closed. 

((^)  Politzer's  method.  Direct  the  padent  to  take  a  mouthful 
of  water ;  insert  the  end  of  the  india-rubber  tube  into  one 
nostril,  carefully  close  the 

unoccupied  portions  of  this  Fig.  213. 

and  the  other  nostril  with 
the  index  finger  and  thumb  ; 
tell  the  patient  to  swallow, 
and  sharply  compress  the 
bag  (Fig.  213).  In  small 
children  the  tympanum  can 

be    inflated   without    their  PoUtzer's  bag. 

drinking  water.     Some  pa- 
tients find  a  difficulty  in  swallov/ing  easily  when  told  to  do  so ; 
such  persons  should  be  made  to  say  some  guttural  word,  such  as 
"  Huck." 

{c)  To  pass  the  Eustachian  catheter  {Y\g.  214),  hold  the  in- 
strument lightly    between    the 

forefinger  and  thumb  and  pass  ^"^-  ^^'^• 

it  quickly  along  the    floor   of  ^^^g»—     •    -  ^^^ 

the  nose,  keeping  the  point  of 
the  instrument  downwards  till 

it     reaches      the     back      of     the         '  Eustachian  catheter. 

pharynx  ;  next  draw  it  forward 

about  three-quarters  of  an  inch,  gently  rotating  outwards  at  the 
same  time,  till  the  point  is  felt  to  ride  over  the  posterior  lip  of 
the  Eustachian  orifice,  and  further  rotating  it  till  the  ring  of  the 
catheter  is  in  a  line  with  the  outer  canthus  of  the  eye,  push  the 
instrument  slowly  onwards,  when  the  point  will  be  in  the 
Eustachian  orifice.  Another  method  for  reaching  the  orifice  of 
the  tube  is  to  draw  the  instrument  forward  over  the  back  of  the 


470  DISEASES   OF   REGIONS. 

soft  palate  till  the  point  begins  to  ride  over  the  posterior  border 
of  the  hard  palate,  then  turn  it  upwards  and  outwards  as  before. 
These  are  the  best  two  methods.  If  the  mucous  membrane  of 
the  nose  be  very  irritable,  first  paint  the  inferior  meatus  with  a  4 
per  cent,  solution  of  cocaine.  Occasionally,  owing  to  post-nasal 
thickening,  deformity  of  the  septum  or  enlargement  of  the  in- 
ferior turbinal,  the  catheter  either  cannot  be  passed,  or  else  when 
passed  cannot  be  turned.  In  such  cases  give  the  catheter  a 
greater  curve,  and  attempt  to  reach  the  tube  through  the  other 
nostril.  When  air  enters  the  tympanum  freely,  it  is  heard  dis- 
tinctly to  impinge  on  the  tympanic  membrane.  If  the  Eustachian 
tube  be  narrowed,  the  air  is  heard  but  feebly,  or  not  at  all,  to 
impinge  on  the  membrane,  li  Jlui'd  he  present,  either- in  the 
tube  or  in- the  tympanum,  a  bubbling  or  gurgling  sound  is  heard. 
If  the  tympanic  membrane  be  pej-forated,  the  air  is  heard  to 
whistle  through  the  perforation.  To  hear  these  sounds  in  the 
tympanum  it  is  necessary  while  inflating  to  use  the  diagfiosttc 
tube,  which  is  nothing  more  than  a  piece  of  india-rubber  tubing 
18  inches  long,  one  end  of  which  is  inserted  into  the  patient's, 
and  the  other  into  the  Surgeon's,  ear. 

Having  thus  examined  the  condition  of  the  external  and  mid- 
dle ear,  the  next  step  is  to  ascertain,  if  possible,  the  condition  of 
the  auditory  nerv^e.  If  a  vibrating  tuning-fork  be  ai)plied  to  the 
vertex  of  the  head  in  the  middle  line  the  sound  is  heard  equally 
in  both  ears.  In  this  case  the  sound  is  conducted  directly  to  the 
labyrinth  by  the  cranial  bones.  If  now  one  meatus  be  closed  by 
the  finger,  the  sound  is  heard  with  greater  intensity  in  that  ear. 
The  explanation  offered  of  this  phenomenon  is  that  many  of  the 
waves  of  sound,  prevented  from  escaping  through  the  tympanum 
and  meatus,  are  thrown  back  and  intensified.  If,  then,  a  patient 
who  is  deaf  on  one  side,  hears  the  tuning-fork  better  with  the 
affected  ear,  it  may  be  assumed  that  the  lesion  is  in  the  sound- 
conducting  apparatus  ;  while  if  he  hears  it  better  with  the  sound 
ear,  some  affection  of  the  labyrinth  or  auditory  nerve  may  be 
suspected.  Another  way  of  testing  the  condition  of  the  labyrinth 
is  to  place  the  vibrating  fork  on  the  mastoid  process  of  the  af- 
fected ear,  and  when  the  patient  can  hear  it  no  longer  for  the 
Surgeon  to  transfer  it  to  his  own  mastoid,  and  note  if  he  can  still 
hear  it  himself.  There  are  certain  rare  exceptions  to  the  truth  of 
what  is  here  stated,  but  it  is  impossible  to  discuss  the  subject  further 
in  so  limited  a  space.  To  complete  the  examination  of  a  patient, 
test  his  hearing  by  means  of  'the  watch  and  voice,  and  finally  ex- 
amine the  nares  and  pharynx  in  cases  where  there  is  reason  for 
suspecting  that  an  unhealthy  condition  of  these  parts  may  be  the 
exciting  cause  of  the  ear- mischief. 


DISEASES   OF   THE   MEATUS.  47 1 

I.  Diseases  of  the  external  ear.  The  auricle  is  liable  to 
attack  from  various  diseases,  but  it  will  only  be  necessary  here  to 
notice  two  :   Eczema  and  Hsematoma. 

Eczema  may  be  acute  or  chronic ;  primary,  or  secondary  to 
eczema  of  the  head.  In  the  acute  form  there  is  great  redness 
and  swelling  of  the  auricle ;  it  is  hot,  tense,  and  tender,  and  later 
a  crop  of  vesicles  appear  which  exude  a  serous  fluid  soon  drying 
into  crusts  ;  these,  when  they  fall  off,  leave  a  raw  surface.  Acute 
eczema  rarely  invades  the  meatus.  The  chronic  variety  may  at- 
tack the  whole  auricle  ;  more  frequently  it  is  limited  to  some  part 
of  it.  There  is  little  or  no  redness,  the  surface  is  dry  and  scurfy, 
and  fissured  in  places,  and  the  disease  generally  spreads  into  the 
meatus,  and  sometimes  even  to  the  drum-membrane.  In  such 
cases  there  is  more  or  less  deafness,  accompanied,  it  may  be,  by 
tinnitus,  and  a  stufly  feeling  in  the  ear.  Treatment. — In  the  acute 
stage  apply  lead  and  opium  lotion,  or  powdered  zinc  and  starch 
in  equal  parts  ;  later,  useful  applications  are  linimentum  calcis,  or 
ung.  hydrarg.  subchlor.  (gj.  ad  53.).  If  the  parts  continue  red  and 
swollen,  paint  them  with  argenti  nitratis  (gss.  ad  aq.  f5J.),  and 
then  apply  powdered  boracic  acid,  or  ung.  hydrarg.  oxidi.  rub. 
(gr.  ij.  ad  5J.).  Applications  to  the  meatus  must  be  applied  with 
a  small  brush ;  the  parts  should  be  washed  with  oatmeal  instead 
of  soap.     Constitutional  treatment  must  not  be  neglected. 

HyEMATOMA  AURis  may  occur  spontaneously  or  as  the  result  of 
an  injury,  and  is  not  uncommon  among  the  insane.  It  consists 
of  an  effusion  of  blood  between  the  cartilage  and  perichondrium 
on  the  anterior  surface  of  the  auricle.  It  occurs  as  a  hard  and 
rarely  fluctuating  swelling,  varying  greatly  in  size.  The  skin 
over  it  is  of  a  more  or  less  livid  hue,  but  occasionally  is  hardly 
discolored.  There  is  a  feeling  of  warmth  or  tingling,  but  rarely 
of  pain.  After  a  time  it  gradually  becomes  smaller  and  may  en- 
tirely disappear.  Sometimes  it  suppurates.  In  the  end  the  auri- 
cle is  left  more  or  less  deformed.  Treatment. — At  first  the 
apphcation  of  ice  or  cooling  lotions ;  some  recommend  tapping 
it  and  injecting  iodine  ;  others  laying  it  open  and  dressing  with  a 
weak  solution  of  carbohc  or  boracic  acid.  Of  course,  if  it  sup- 
purates, it  must  be  opened  freely. 

II.  Diseases  of  the  meatus  : — Diffuse  inflammation  is  caused 
by  injury,  irritants  (such  as  scratching  the  meatus  with  a  pin),  or 
sea-bathing.  There  is  redness  and  swelling  of  the  skin  fining  the 
meatus,  a  sense  of  fulness,  and  throbbing  and  occasional  tinnitus, 
followed  by  serous  or  semi-purulent  secretion.  After  a  time  the 
epithelial  fining  becomes  v/hitish  and  sodden,  and,  on  syringing, 
comes  away  in  flakes,  or  even  as  a  cast  of  the  meatus,  leaving  the 
surface  beneath  red,  and  frequently  obliterating  the  demarcation 


472  DISEASES   OF   REGIONS. 

between  the  meatus  and  tympanic  membrane.  Rarely  the  tym- 
panic membrane  may  be  perforated.  There  is  pain,  increased 
by  movements  of  the  jaw  or  pressure  on  the  auricle,  and  some- 
times fever.  Treatment — In  the  early  stages  cold  compresses, 
and  a  leech  or  two  to  the  tragus  ;  and  antiphlogistics.  As  soon 
as  secretion  is  established,  instil  a  warm  solution  of  boracic  acid, 
and  later  equal  parts  of  alcohol  and  water,  or  blow  in  powdered 
boracic  acid.  If  the  discharge  proves  obstinate,  the  surface  may 
be  painted  with  a  solution  of  nitrate  of  silver  (,5ss.  ad  foJ-)>  or 
liquor  plumbi  subacetatis. 

Furuncles.  Small  boils  frequently  occur  in  the  meatus  in 
gouty,  anaemic,  and  diabetic  patients  ;  also  in  those  whose  nervous 
system  has  been  greatly  taxed.  The  attack  begins  with  pain, 
often  of  the  greatest  intensity,  radiating  over  the  side  of  the  head 
and  increased  by  movements  of  the  jaw,  or  the  slightest  pressure 
on  the  auricle.  There  may  be  deafness  as  the  result  of  closure  of 
the  meatus,  not  otherwise.  Examination  shows  little  or  no  redness, 

but  one  or  more  swellings. 
Fig.  215.  often    closing    the    meatus. 

These  are  exquisitely  tender 
when  touched.  As  soon  as 
the  abscess  bursts  the  pain 
subsides,  but  very  often  one 
abscess  after  another  forms, 
till  the  patient's  life  be- 
comes a  burden  to  him 
through  pain  and  sleepless- 
Aurai  forceps.  ^gss.      Treatment.  —  Apply 

hot  fomentations,  a  leech 
or  two  to  the  tragus,  and  instil  a  concentrated  solution  of  boracic 
acid  in  alcohol.  Often  a  plug  of  cotton-wool  soaked  in  glycerine 
and  laudanum,  and  gently  inserted  into  the  meatus  by  the  aural 
forceps  shown  at  Fig.  215,  or  Oruber's  medicated  gelatin  bougies, 
give  relief.  When  the  abscess  is  fully  formed  incise  it,  but  not 
before,  as  early  incision  is  excessively  painful  and  gives  but  tem- 
porary relief.  The  general  health  should  be  attended  to,  and  full 
doses  of  opium  given  to  procure  sleep.  Von  Troltsch  recom- 
mends arsenic  to  prevent  the  recurrence  of  furuncles. 

Impaction  of  cekumkn  may  be  caused  by  narrowing  of  the 
meatus,  cleaning  the  ears  with  the  end  of  a  towel  or  ear- pick,  or 
the  presence  of  a  foreign  body,  such  as  a  piece  of  cotton-wool  in- 
serted into  the  meatus  and  forgotten.  The  chief  syt>ipto//i  is 
partial  or  complete  deafness,  generally  coming  on  suddenly. 
'J'here  may  be  tinnitus  or  even  giddiness,  often  persistent  cough, 
rarely  pain.     Sometimes  the  impaction  of  cerumen  is  really  due 


AURAL    EXOSTOSES.  473 

to  a  peculiar  laminated  desquamation  of  the  skin  of  the  meatus, 
which  becomes  mixed  with  wax,  and  thus  forms  a  plug.  Treat- 
7nent. — If  the  wax  be  not  very  hard,  it  can  be  at  once  removed  by 
syringing  with  warm  water,  the  auricle  being  pulled  backwards 
and  upwards,  and  the  nozzle  of  the  syringe  directed  along  the 
upper  and  posterior  wall.  If  any  difficulty  be  experienced  in  re- 
moving the  wax  owing  to  its  hardness,  soften  it  first  by  dropping 
into  the  ear  for  a  few  nights  a  warm  solution  of  bicarbonate  of 
soda  (gr.  x.  ad  f^j.).  After  removal  gently  dry  the  meatus  with 
a  cone  of  absorbent  wool,  and  let  the  patient  keep  a  piece  in  the 
meatus  for  a  few  hours. 

Otomycosis  is  a  chronic  inflammation  of  the  external  auditory 
meatus,  due  to  the  presence  of  a  vegetable  fungus.  The  symptoms 
are  a  sense  of  fulness,  tinnitus  and  occasional  vertigo,  more  or 
less  itching,  and  occasionally  pain.  On  examination  there  is 
seen  a  slight  serous  discharge,  and  the  meatus  contains  yellowish 
or  blackish  flakes,  on  removal  of  which  the  skin  beneath  is  found 
to  be  reddened  and  occasionally  bleeding.  Microscopical  exami- 
nation of  the  flakes  at  once  reveals  the  parasitic  nature  of  the 
disease. 

The  Treatment  consists  in  frequently  syringing  with  a  warm 
solution  of  perchloride  of  mercury  (i  in  looo),  or  chlorinated 
lime  (gr.  ij.  ad  f.^j.),  or  hyposulphite  of  soda  (gr.  iv.  ad  f3J.), 
and,  when  the  meatus  is  thoroughly  freed  from  the  flakes,  instill- 
ing alcohol. 

Aural  exostoses  may  roughly  be  divided  into  the  spongy  and 
the  ivory. 

{a)  The  Spongy  are  single  and  generally  pedunculated,  are 
most  comimonly  found  at  the  junction  of  the  cartilaginous  and 
bony  meatus,  are  rapid  in  growth,  follow  suppuration  of  the  mid- 
dle ear,  and  are  frequently  the  result  of  ossification  of  granula- 
tions. Treatment. — They  can  generally  be  removed  by  seizing 
them  with  a  pair  of  forceps  and  breaking  them  off". 

(^)  The  Ivory  exostoses  or  rather  hyperostoses  may  be  single, 
but  are  more  often  niultiple.  They  vary  from  ridge-like  eleva- 
tions to  rounded  tumors  with  broad  bases  ;  they  are  found  near 
the  orifice  of  the  meatus,  more  or  less  blocking  up  the  canal,  and 
grow  slowly.  Syphilis,  gout,  irritation  of  the  meatus,  and  sea- 
bathing are  said  to  be  the  exciting  causes.  Treatment. — They 
should  not  be  interfered  with  unless  they  cause  deafness  by  com- 
pletely closing  the  meatus,  except  in  those  rare  cases  where  they 
are  associated  with  discharge.  In  such  cases,  as  they  greatly  lessen 
the  lumen  of  the  canal,  they  should  be  removed  to  avoid  the  risk 
of  pent-up  matter.  When  their  removal  is  necessary,  this  should 
be  done  by  means  of  a  chisel  and  hammer,  or  the  dental  drill.  ■ 

20* 


474  DISEASES   OF   REGIONS. 

III.  Diseases  of  the  middle  ear  : — Acute  catarrh  may  be 
started  by  any  condition  which  produces  acute  naso-pharyngeal 
catarrh,  such  as  a  severe  cold,  the  exanthemata,  etc.  It  may  also 
be  caused  by  sea-bathing,  or  by  the  use  of  the  nasal  douche. 
Sy?upto»is. — The  attack  begins  by  a  feeling  of  fulness  in  the  head, 
followed  by  pain,  which  varies  in  character  from  a  dull  aching  to 
a  severe  throbbing  or  stabbing  ;  there  is  more  or  less  deafness,  and 
sometimes  tinnitus,  and  even  giddiness,  and  in  severe  cases  febrile 
disturbance.  On  examination,  the  membrane  shows  at  first  but 
little  change  beyond  a  slight  loss  of  lustre,  and  the  presence  of  a 
fine  streak  of  red  along  the  posterior  edge  of  the  malleus-handle. 
In  severe  cases,  the  posterior  segment  of  the  membrane  and  the 
adjacent  meatus  are  red,  and  this  redness  may  spread  over  the 
entire  membrane  till  the  outline  of  the  malleus-handle  is  lost. 
Vesicles  and  even  small  abscesses  may  form  on  its  surface.  Later 
the  epidermis  is  loosened  in  white  flakes,  and  finally  the  membrane 
distinctly  bulges,  when  the  effusion  of  fluid  is  great.  The  Eu- 
stachian tube  is  closed  by  swelling  of  its  lining  membrane.  After 
some  days,  varying  with  the  severity  of  the  inflammation,  resolu- 
tion begins,  or  the  fluid  (mucus  or  pus)  bursts  through  the  mem- 
brane, and  is  discharged  into  the  meatus.  2'reatnient. — The 
patient  should  be  confined  to  the  house,  or  even  to  his  bed,  ac- 
cording to  the  severity  of  the  attack.  An  aperient  should  be  at 
once  given,  and  an  astringent  gargle.  If  the  pain  is  severe,  a 
leech  or  two  should  be  applied  to  the  tragus.  Cold  compresses 
should  as  a  rule  be  avoided,  but  hot  fomentations  are  grateful  to 
the  patient  and  generally  useful.  The  ear  may  also  be  gently 
syringed  with  warm  water.  If  there  be  distinct  bulging  the  mem- 
brane should  be  incised,  especially  if  the  pain  persists.  If  there 
be  any  tenderness  over  the  mastoid,  this  should  also  be  leeched. 
After  the  severity  of  the  symptoms  has  subsided,  the  tympanum 
should  be  inflated  daily  by  means  of  the  air-douche,  and  if  the 
discharge  continues,  the  ear  syringed  with  a  warm  solution  of 
boracic  acid  (1-40),  night  and  morning,  and  a  lotion  of  sulphate 
of  zinc  (gr.  v.  ad  f5J.),  or  equal  parts  of  rectified  spirit  and  water 
instilled ;  or  after  syringing  with  warm  water  and  drying  the 
meatus  with  absorbent  wool,  powdered  boracic  acid  may  be  blown 
in.  If  the  catarrh  is  non-purulent  the  membrane  is  rarely  per- 
forated ;  and  even  if  perforation  occurs,  the  aperture  speedily 
heals  after  the  escape  of  the  fluid.  Inflation  by  means  of 
Politzer's  bag  should  be  continued  with  decreasing  frequency  till 
the  hearing  is  restored. 

Chronic  purulent  catarrh  (pojnilarly  called  Otorrhaa)  fol- 
]  •.  J  the  acute  form  of  disease.  After  freeing  the  ear  from  dis- 
tl.  .  rje,  the   membrane    appears    thickened,   yellowish   from  the 


CHRONIC  PURULENT  CATARRH.  475 

presence  of  sodden  epithelium,  or  if  this  has  been  removed,  red- 
dish in  hue.  In  some  part  of  it  a  perforation  can  usually  be  de- 
tected, varying  in  size,  the  margins  granular  or  clean  cut.  If  large, 
the  lining  membrane  of  the  tympanum  can  also  be  seen,  varying 
in  color  from  pale  pink  to  dark  red,  according  to  the  degree  of 
inflammation  present.  When  very  small  and  situated  anteriorly, 
the  perforation  sometimes  cannot  be  seen,  but  its  existence  can 
be  proven  by  inflating  the  tympanum  and  listening  with  the  diag- 
nostic tube.  The  amount  of  deafness  present  in  chronic  purulent 
catarrh  varies  greatly.  There  is  rarely  tinnitus,  but  giddiness  is 
far  from  uncommon.  It  is  in  this  form  of  disease  that  patients 
are  specially  liable  to  the  complications  which  will  be  considered 
later.  Treatment. — After  attention  to  the  general  health,  the 
most  important  part  of  the  treatment  is  great  cleanliness.  If  a 
quantity  of  half-dried  secretion  mixed  with  epithelial  debris  be 
found  in  the  meatus,  this  should  first  be  removed  by  the  instilla- 
tion of  warm  bicarbonate  of  soda  (gr.  x.  ad  f5J.)  for  several 
nights,  and  then  thoroughly  syringing  the  ear.  Next  let  the  ear 
be  syringed  with  warm  boracic  acid  night  and  morning,  and  after 
drying  the  meatus  blow  in  powdered  boracic  acid.  If  this  treat- 
ment be  unsuccessful,  then  try  an  alcoholic  solution  of  boracic 
acid  ;  or  if  this  causes  pain,  the  solution  may  at  first  be  diluted 
with  an  equal  quantity  of  water.  Or  sulphate  of  zinc  (gr.  x.  ad 
f5J.),  or  acetate  of  lead  (gr.  iij.  ad  f^j.)  may  be  tried. 

If  the  perforation  be  large  and  the  mucous  membrane  of  the 

Fig.  216. 


Forceps  for  inserting  artificial  drum. 

tympanum  much  swollen,  it  should  be  touched  with  solid  nitrate 
of  silver,  or  a  saturated  solution  of  chromic  acid.  Often  when 
the  discharge  has  ceased,  the  membrane  remains  perforated,  and 
there  is  considerable  deafness.  In  such  cases  the  hearing  may 
be  greatly  improved  by  means  of  an  artificial  membrane. 

Without  here  discussing  how  the  artificial  membrane  acts,  it  is 
sufficient  to  say  there  are  two  kinds,  known  as  Yearsley's  and 
Toynbee's.  i.  F^arj-Z?r'.y  consists  of  a  piece  of  moistened  cotton- 
wool, rolled  into  an  elongated  pUig,  and  appUed  with  a  pair  of 
forceps  specially  designed  for  the  purpose  (Fig.  216).  2.  Toynbee's 
consists  (Fig.  217)  of  a  disk  of  soft  india-rubber  with  a  piece  of 
silver  wire  attached  to  the  centre.  The  former  has  the  advantage 
of  being  less  irritating  to  the  ear,  and  can  be  moistened   with 


476 


DISEASES   OF   REGIONS. 


Fig.  217. 


Toynbee's  artificial  drum. 


Fig.  218. 


medicated  fluids,  should  any  discharge  still  persist,  but  it  has  the 
disadvantage  of  being  more  difficult  to  apply.  Toynbee's  is 
easily  applied,  but  it  is  more  irritating  to  the  ear.  There  are 
various  modifications  of  Toynbee's,  the  best  being  Gruber's.  It 
is  impossible  to  tell  in  any  given  case  whether  the  artificial  drum 
will  succeed ;  this  can  only  be  ascertained  by  trial.  When  suc- 
cessful the  artificial  drum  should  only  be  worn  at  first  for  a  few 

hours.  The  length  of  time  should 
gradually  be  increased  as  the  ear 
becomes  accustomed  to  its  pres- 
ence. It  should  always  be  re- 
moved at  night. 

Various  complications  may  arise 
in  the  course  of  chronic  purulent 
catarrh.     These  are  i,  polypi;  2, 
mastoid  disease  ;  3,  caries  and  necrosis  ;  4,  meningitis  and  intra- 
cranial suppuration  ;  and  5,  phlebitis  and  septicaemia. 

(i)  Polypi  may  grow  from  the  tympanic  membrane,  the 
meatus,  or  the  tympanic  cavity.  Those  growing  from  the  meatus 
are  not  true  polypi ;  but  for  brevity  they  will  all  be  classed  under 

the  name  of  polypi.  They  vary 
much  in  size,  being  sometimes  not 
larger  than  a  mustard  seed,  at  other 
times  large  enough  to  project  be- 
yond the  external  orifice  of  the 
meatus.  They  are  usually  bright 
red  in  color,  but  may  be  pale  pink, 
and  when  very  large  greyish  yellow. 
They  bleed  more  or  less  readily 
when  touched.  The  diagnosis  is 
easily  made,  but  care  must  be  taken 
not  to  mistake  a  swollen  and  vas- 
cular membrane  for  a  polypus.  In  case  of  doubt  the  mobility  of 
the  latter,  when  touched  with  a  probe,  will  settle  the  point. 
Treatment. — Polypi  growing  from  the  tympanic  membrane  should 
be  destroyed  with  a  saturated  solution  of  chromic  acid  or  per- 
chloride  of  iron  applied  by  means  of  a  piece  of  cotton-wool 
twisted  round  a  fine  pair  of  forceps  (Fig.  215).  When  the 
growth  springs  from  the  meatus,  and  is  not  too  far  in,  it  can 
easily  be  pinched  off  with  a  pair  of  aural  forceps  ;  when  deeper 
in,  it  can  be  scraped  off  with  a  small  sharp  spoon.  'I'hose  of 
larger  size,  especially  when  arising  in  the  tympanic  cavity,  should 
ta  removed  by  the  snare  (l''ig.  218).  If  the  growth  be  of  large 
size,  of  long  duration,  and  firm  in  structure,  it  is  most  easily  re- 
moved by  seizing  it  with  a   pair  of  dressing-forceps,  and  slowly 


^olypus  snare. 


CARIES   AND   NECROSIS.  477 

twisting  it  round  on  its  own  axis.  Care  must  be  taken  to  fix  the 
patient's  head  in  order  to  avoid  sudden  movement  on  his  part. 
However  removed,  the  root  of  the  polypus  must  be  touched  with 
a  saturated  sokition  of  chromic  acid  or  perchloride  of  iron  till  it 
is  quite  destroyed.  During  the  time  occupied  in  destroying  the 
root,  the  ear  must  be  syringed  twice  a  day  with  warm  water,  and 
alcohol  dropped  into  the  meatus  and  retained  there  some  minutes. 

(2)  Mastoid  disease. — Not  unfrequently  inflammation  of  the 
tympanum  spreads  to  the  mastoid  cells,  especially  to  the  large 
irregular  cell  {mastoid  aninim)  situated  just  behind  and  slightly 
above  the  external  auditory  meatus.  The  symptoms  are  deep- 
seated  pain,  tenderness  on  pressure,  and  when  the  periosteum  is 
involved,  redness  and  swelling ;  and  the  ear  projects  more  or  less 
unduly  from  the  side  of  the  head.  In  many  cases  after  a  while, 
there  is  fluctuation,  and  on  opening  the  abscess,  the  bone  beneath 
is  felt  to  be  bare.  Sometimes  there  is  a  fistulous  opening  com- 
municating with  the  mastoid  cells.  If  the  abscess  is  not  opened, 
the  matter  may  burrow  downwards  beneath  the  sterno-mastoid,  or 
backwards  beneath  the  muscles  attached  to  the  occiput.  In 
severe  cases  there  may  be  signs  of  cerebral  irritation.  Some- 
times the  signs  are  very  obscure,  there  being  little  indication  of 
the  mischief  beyond  deep-seated  pain,  tenderness  on  making  firm 
pressure,  and  some  fever.  It  is  in  such  cases  that  the  inflamma- 
tion is  apt  to  spread  to  the  cranial  cavity.  Occasionally  the  in- 
flammatory products  ossify,  and  convert  the  mastoid  cells  into 
solid  bone.  Tj-eatment. — In  the  early  stages  apply  hot  fomenta- 
tions and  leeches,  and  as  soon  as  fluctuation  can  be  detected, 
make  a  free  incision  into  the  swelling,  and  encourage  the  dis- 
charge from  the  tympanum  by  frequent  syringing  with  warm 
water.  In  obscure  cases,  if  the  pain  persists,  and  the  temperature 
keeps  above  the  normal,  trephine  the  mastoid  cells  or  open  the 
cells  and  antrum  by  means  of  a  mallet  and  chisel.  There  is  little 
danger  in  trephining  the  mastoid  cells,  if  care  be  taken  to  avoid 
wounding  the  lateral  sinus. 

(3)  Caries  and  necrosis. — The  parts  of  the  temporal  bone 
most  frequently  attacked  are  the  mastoid  process,  the  posterior 
wall  of  the  meatus,  and  the  roof  of  the  tympanic  cavity.  It  is 
generally  easy  to  make  a  diagnosis,  but  when  the  deeper  parts  are 
affected  it  may  not  be  possible  to  do  so  with  certainty.  The 
points  that  will  help  the  surgeon  are,  facial  palsy,  the  persistence 
of  offensive  discharge  in  spite  of  cleanhness,  and  granulations  re- 
sisting all  attempts  at  destruction.  Even  then  it  may  be  neces- 
sary to  put  the  patient  under  an  anaesthetic,  and  carefully  examine 
with  a  probe.  Treatment. — If  the  diseased  bone  can  be  reached 
without  further  injuring  the  hearing,  it  should  be  freely  scraped  or 
removed. 


478  DISEASES   OF   REGIONS. 

(4)  Meningitis  akb  intracranial  suppuration. — Although 
meningitis  may  supervene  in  the  course  of  acute  purulent  catarrh 
of  the  middle  ear,  it  is  generally  in  the  course  of  the  chronic 
disease  that  it  arises.  Intracranial  suppuration  may  occur  be- 
tween the  dura  mater  and  the  bone — subdural  abscess — or  in  the 
cerebrum  or  cerebellum.  Subdural  abscess  is  generally  found  on 
the  roof  of  the  tympanum  or  on  the  posterior  surface  of  the 
petrous  bone ;  cerebral  abscess  in  the  hinder  part  of  the  middle 
temporo-sphenoidal  lobe  ;  cerebellar  abscess  in  the  anterior  part 
of  the  lateral  lobe.  If  in  the  course  of  chronic  suppuration, 
headache,  rigors,  and  a  rise  of  temperature  supervene,  we  may 
strongly  suspect  intracranial  mischief;  and  if  in  addition  there  is 
photophobia,  sluggish  pupils  and  optic  neuritis,  the  diagnosis  is 
all  but  certain.  Treatment — If  the  symptoms  point  to  the  prob- 
ability of  intracranial  abscess,  the  skull  should  be  trephined,  and 
an  attempt  made  to  reach  the  pus. 

The  position  of  the  trephine  openings  to  reach  matter  are  the 
following: — {a)  to  reach  the  mastoid  antrum  the  centre  of  the 
trephine  opening  should  be  Vq,  inch  behind,  and  3^  inch  above  the 
centre  of  the  external  auditory  meatus  ;  {b)  to  expose  the  anterior 
surface  of  the  petrous  bone,  and  roof  of  the  tympanum,  the  centre 
of  the  opening  should  be  y%  inch  above  the  middle  of  the  meatus  ; 
(r)  to  expose  the  lateral  sinus,  the  opening  should  be  i^  inch 
behind,  and  Y^  inch  above  the  middle  of  the  meatus  ;  {^d)  to 
reach  a  temporo-sphenoidal  abscess,  trephine  x^  inch  behind, 
and  i^  inch  above  the  meatus  ;  {e)  to  reach  a  cerebellar  abscess, 
trephine  i  ^^  inch  behind,  and  i^  inch  below  the  middle  of  the 
meatus.  Use  a  half-inch  trephine,  and  afterwards  enlarge  the 
opening  when  necessary  with  chisel,  gouge,  forceps,  etc. 

(5)  Phf-ebitis  and  SEFric/EMiA. — Phlebitis  of  the  lateral  sinus 
may  supervene  in  the  course  of  suppuration  of  the  middle  ear, 
especially  when  there  is  caries  of  some  part  of  the  tympanic  walls. 
When  followed  by  septic  poisoning,  the  symptoms  are  headadie, 
vomiting,  and  rigors,  with  great  rise  in  temperature,  sweating  and 
tenderness  over  the  mastoid,  and  in  the  course  of  the  internal 
jugular  vein.  'J'here  is  also  frequently  pain  on  making  firm  pres- 
sure at  the  posterior  border  of  the  mastoid  processes,  and,  oc- 
casionally, local  (jederna,  and  sometimes  optic  neuritis. 

Treatment. — 'I'rephine  the  mastoid,  and  if  the  sinus  be  found 
])lugged,  ligature  the  internal  jugular  vein  in  two  places,  and  di- 
vide it  between  the  ligatures.  Now  lay  open  the  lateral  sinus, 
and,  removing  the  clot,  thoroughly  wash  out  the  sinus  with  a  weak 
solution  of  perchloride  of  mercury.  If  in  doubt  as  to  whether 
the  lateral  sinus  is  plugged  or  not,  a  fine  trocar  and  cannula  may 
first  be  inserted  into  it. 


CHRONIC    NON-PURULENT    CATARRH.  479 

Chronic  non-purulent  catarrh. — By  far  the  largest  propor- 
tion of  cases  of  deafness  met  with  are  due  to  chronic  catarrh.  So 
many  pathological  conditions  are  included  under  this  heading, 
that  it  is  impossible  to  do  more  than  give  a  very  general  outUne 
of  the  symptoms.  The  affection  may  result  from  an  acute  attack, 
but  more  generally  is  a  chronic  affection  from  the  very  first. 
Heredity,  syphilis,  gout,  rheumatism,  and  gestation,  are  predis- 
posing, and  perhaps  in  some  cases,  exciting  causes.  Large  doses 
of  quinine,  long  continued,  may  also  be  an  exciting  cause.  The 
disease  at  first  progresses  so  insidiously,  as  often  to  remain  un- 
suspected for  some  time.  In  many  cases,  tinnitus  is  the  first  and 
perhaps  for  a  time  the  only  symptom.  More  often,  however,  the 
earhest  symptom  is  slight  dfficulty  of  hearing  general  conversa- 
tion ;  later  there  is  tinnitus,  at  first  intermittent,  afterwards  per- 
sistent. Gradually  the  deafness  increases  till  it  becomes  marked. 
This  deafness  varies  greatly  with  the  state  of  the  weather  and  the 
patient's  general  health.  There  is  rarely  pain,  and  when  present, 
it  is  transient,  and  never  severe.  There  is  often  a  sense  of  tight- 
ness in  the  head,  and  a  feeling  as  if  the  ears  were  stopped  with 
cotton- wool.  Sometimes  there  is  giddiness,  and  some  patients 
hear  perfectly  in  a  vibrating  noise,  as  for  instance,  in  a  railway 
carriage.  On  inspection,  the  meatus  is  dry  and  shining ;  and  oc- 
casionally it  contains  impacted  cerumen,  the  removal  of  which, 
however,  causes  no  improvement  in  hearing.  The  membrane 
varies  greatly  in  appearance.  At  times  it  is  normal,  oftener  more 
or  less  opaque  ;  rarely  is  there  any  sign  of  congestion.  The  an- 
terior segment  may  be  retracted,  the  handle  of  the  malleus  being 
sharply  defined,  or  the  entire  membrane  may  be  cupped,  and  the 
handle  drawn  inwards  and  backwards.  Opacities,  calcareous  de- 
posits, and  thinned  spots  are  often  seen.  The  cone  of  light  may 
be  altered  in  direction,  may  be  broken  into  points,  or  may  disap- 
pear. Rhinoscopic  examination  may  show  the  naso -pharyngeal 
raucous  membrane  swollen,  congested  and  granular,  or  pale  and 
dry.  Adenoid  vegetations  may  be  present.  The  Eustachian 
orifice  may  be  obliterated  by  cicatricial  bands,  or  variously  dis- 
torted. Inflation  may  prove  the  canal  patent,  or  more  or  less 
obstructed.  If  the  labyrinth  be  not  seriously  involved,  the  tuning- 
fork  is  heard  louder  in  the  affected  ear.  Treatment. — The  nasal 
cavity  and  pharynx  should  be  examined  and  as  far  as  possible  re- 
stored to  a  healthy  condition  (see  diseases  of  nose  and  pharynx). 
The  patency  of  the  Eustachian  tube  must  be  restored,  if  possible, 
by  means  of  the  air-douche,  catheter,  or  electric  bougie.  The 
nostrils  should  be  syringed  through  v/ith  warm  saline  solutions, 
and  astringent  gargles  when  necessary  should  be  given,  or  the 
throat  painted  with  nitrate  of  silver,  chloride  of  zinc  or  glycerine 


480  DISEASES   OF   REGIONS. 

of  tannin.  If  these  means  fail,  the  chloride  of  ammonium  inhaler 
may  be  tried,  or  medicated  fluids  may  be  injected  into  the  tym- 
panum, such  as  bicarbonate  of  potash,  iolide  of  potassium,  vapor 
of  iodine,  or  pilocarpine,  although  I  cannot  say  I  have  observed 
much  benefit  from  their  use.  Some  Surgeons  recommend,  in 
obstinate  cases,  peforating  the  membrane,  and  dividing  the  tensor 
tympani,  the  posterior  fold,  or  the  anterior  ligament  of  the  malleus. 

IV.  Diseases  of  the  internal  ear. — Our  knowledge  of 
diseases  of  the  internal  ear  is  still  so  iipperfect,  and  our  means  of 
treatment  so  inadequate,  that  this  part  of  the  subject  need  not  be 
discussed  at  any  great  length.  Diseases  of  the  internal  ear, 
although  often  primary,  are  more  frequently  secondary  to  diseases 
of  the  middle  ear.  Jlie  causes  are: — 1.  General  diseases  of  the 
system,  especially  the  zymotic  diseases,  such  as  scarlet-fever, 
measles,  mumps,  typhus,  diphtheria,  etc. ;  also  anaemia,  lactation, 
and  especially  syphilis.  2.  Extension  from  the  middle  ear,  either 
directly  or  indirectly  by  causing  reflex  vaso-motor  changes  in  the 
labyrinth.  3.  Intracranial  mischief,  such  as  aneurysm  of  the 
basilar  artery,  meningitis,  abscess  or  tumors.  4.  Sudden  loud 
noises,  such  as  heavy  artillery  firing.  5.  Great  emotion;  and  6. 
Continued  use  of  large  doses  of  quinine.  The  chief  points  of  diag- 
nostic value  are  : — i.  The  vibrating  tuning-fork  placed  on  the 
middle  line  of  the  head  is  heard  less  distinctly  with  the  deaf  ear, 
or  if  both  ears  be  affected,  it  is  not  heard  at  all  or  very  indis- 
tinctly. 2.  The  tuning-fork  when  it  has  ceased  to  be  heard 
through  the  cranial  bones,  can  still  be  heard  when  placed  opposite 
the  meatus.  3.  The  tuning-fork  when  it  has  ceased  to  be  heard 
by  the  patient,  can  still  be  heard  by  the  Surgeon.  4.  The  patient 
hears  the  tick  of  the  watch  proportionately  better  than  speech. 
5.  There  is  generally  nausea  or  vomiting,  giddiness,  and  always 
tinnitus.  None  of  these  signs  and  symptoms  when  taken  sepa- 
rately are  of  much  value,  but  when  taken  together,  they  are  strong 
presumptive  evidence  of  mischief  in  the  internal  ear. 

Meniere's  disease  is  a  sudden  hsemorrhagic  effusion  into  the 
labyrinth.  The  symptoms  are  very  marked.  The  patient,  whose 
hearing  was  more  or  less  perfect  before  the  attack,  is  suddenly 
seized  with  intense  tinnitus  and  giddiness,  often  so  great  as  to 
cause  him  to  fall.  The  giddiness  is  followed  by  nausea  or  actual 
vomiting,  faintness,  and  cold  sweats.  (Jn  recovering  somewhat, 
he  finds  he  is  deaf  with  one  ear.  The  giddiness  sooner  or  later 
passes  off,  but  the  tinnitus  and  deafness  persist.  If  the  deafness 
is  absolute,  the  tinnitus  may  eventually  disappear.  Treatment. — 
Quinine,  bromide  of  potassium,  subcutaneous  injections  of  pilo- 
carpine, and  electricity  are  recommended ;  but  all  treatment 
directed  towards  restoring  the  hearing  is  generally  useless. 


TINNITUS  AURIUM.  48 1 

Auditory  vertigo  is  characterized  "by  a  sensation  of  motion, 
referred  by  the  patient  either  to  himself,  or  to  surrounding  objects, 
which  seem  to  revolve  in  certain  defined  planes"  (McBride). 
The  attacks  are  generally  paroxysmal,  but  often  there  is  more  or 
less  constant  giddiness,  with  occasional  exacerbations.  As  may  be 
seen  above,  auditory  vertigo  is  a  prominent  symptom  in  Meniere's 
disease,  but  many  causes  may  give  rise  to  the  symptom,  such  as 
(a)  increased  pressure  on  the  secondary  membranes  of  the  tym- 
panum induced  by  accumulations  of  wax  in  the  meatus,  forcible 
syringing,  or  retraction  of  the  membrana  tympani  due  to  obstruc- 
tion of  the  Eustachian  tube;  {^)  fluid  accumulations  in  the 
tympanic  cavity ;  (c)  vascular  and  nervous  changes,  or  effusion 
and  secondary  formations  in  the  labyrinth  itself;  {d)  intra- 
cranial lesions  ;  (e)  dyspepsia,  and  (/)  such  drugs  as  quinine  and 
salicin.  Treatment. — The  treatment  consists  in  finding  the  cause, 
if  possible,  and  attempting  to  remove  it.  When  this  is  impos- 
sible, large  doses  of  bromide  of  potassium,  alone  or  combined 
with  hydrobromic  acid,  will  be  found  most  efficacious.  Next, 
quinine  in  large  doses,  but  this  must  be  carefully  watched  ;  and 
lastly,  the  use  of  the  continuous  current  of  electricity. 

Tinnitus  aurium  arises  under  most  varied  conditions.  The 
sounds  complained  of  are  very  numerous,  but  may  be  divided  into 
ringing,  rushing,  bubbling,  and  pulsating  sounds.  Any  abnormal 
condition  of  the  auditory  apparatus  will  produce  it,  such  as — i, 
accumulations  of  wax  pressing  on  the  drum-membrane  ;  2,  in- 
creased intra- labyrinthine  tension,  from  undue  pressure  on  the 
fenestrse  (either  by  fluid  in  the  tympanum,  or  retraction  of  the 
membrana  tyaipani  through  obstruction  of  the  Eustachian  tube)  ; 
or  lastly,  hypersemia  of,  or  pathological  change  in,  the  labyrinth. 
But  in  addition  to  these  local  causes  tinnitus  may  be  produced  by 
causes  acting  at  a  distance,  such  as  aucemia,  chlorosis,  pulsating 
exophthalmos,  aneurysm  of  the  vertebral  artery,  cerebral  disease, 
large  doses  of  quinine,  or  salicin.  Treatment. — In  every  case  it 
is  important,  if  possible,  to  ascertain  whether  the  cause  is  to  be 
found  in  some  derangement  of  the  auditory  apparatus,  or  else- 
where. If  the  cause  be  local,  it  is  generally  possible  to  reheve  or 
cure  the  tinnitus  by  curing  the  local  affection.  If  the  tinnitus 
depends  on  general  anaemia,  some  form  of  iron,  with  a  generous 
diet  and  the  addition  of  stimulants  may  be  sufficient  to  effect  a 
cure.  If  there  be  hyperassthesia  of  the  nervous  system,  the 
bromides  are  indicated,  with  the  addition  of  hydrobromic  acid,  if 
the  singing  is  of  a  pulsating  character.  Tinnitus  frequently  occurs 
in  patients  of  a  rheumatic  diathesis,  and  in  such,  anti- rheumatic 
treatment  is,  of  course,  indicated.  Other  remedies  failing,  the 
Surgeon,  empirically,  may  try  chloride  of  ammonium,  nitrite  ot 
soda,  and  lastly,  the  continuous  current  of  electricity. 
21 


482  DISEL-^SES    OF    REGIONS. 

DISEASES    OF    THE    EVE. 

By  Walter  H.  Jessop,  M.  B.,  F.  R.  C.  S.,  Ophthalmic  Surgeon  to  St. 
Bartholomew's  Hospital. 

Physical  examination  of  the  eye. — For  the  complete  and 
thorough  examination  of  the  eye  it  is  necessary  that  it  should  be 
examined  : — (i)  by  the  unaided  eye  or  by  focal  illumination  ;  (2) 
by  the  ophthalmoscope;  (3)  for  acuteness  of  vision,  fields  of 
vision,  color-sense,  and  tension.  In  all  cases  where  practicable 
each  observation  on  the  one  eye  should  be  repeated  on  the  other 
for  comparison. 

(i )  Seating  the  patient  in  front  of  a  window,  or  in  a  dark  room 
with  the  lamp  to  the  left  and  about  two  feet  in  front  of  him,  direct 
and  concentrate  the  light  on  his  eye  by  a  biconvex  lens  of  about 
2^  inches  focal  length  {focal  illiiviination^ .  First  look  at  the 
lids,  and  tell  him  to  open  and  shut  them  ;  then,  with  the  hds  open, 
to  execute  the  various  complete  in,  out,  down  and  up  movements 
of  the  eye  to  test  the  extrinsic  ocular  muscles.  Along  the  edges 
of  the  lids  look  for  the  puncta  which  ought  to  be  applied  close  to 
the  ocular  conjunctiva.  Press  near  the  inner  canthus  over  the 
lachrymal  sac  to  see  if  any  discharge  passes  through  the  puncta. 
Evert  the  upper  lid  to  examine  its  conjunctival  surface  by  direct- 
ing the  patient  to  look  down  to  the  ground,  laying  a  probe  hori- 
zontally on  the  external  surface  of  the  lid  and  then  taking  hold  of 
the  lashes  turn  the  lid  over  the  probe.  Pull  down  the  lower  lid  to 
examine  its  conjunctival  surface. 

The  ocular  conjunctiva  should  be  transparent-looking  and  a 
few  small  vessels  should  be  seen  through  it  perforating  the  white 
or  bluish  sclerotic.  Just  external  to  the  inner  canthus  is  a  small 
greyish-red  projection,  the  caruncle,  and  extending  from  it  a 
pinkish  fold,  \\\q.  plica  semilunaris. 

The  vessels  seen  in  inflammations  of  the  eye  may  be  divided 
into  the  following: — i.  '\\\t  poskrioi  conjunctival.  These  are 
generally  brick- red  in  color,  tortuous,  movable  with  the  con- 
junctiva, and  disappear  on  pressure.  2.  The  suh-coiijunctival  'Mt 
branches  or  radicles  of  the  anterior  ciliary  vessels  and  arc  divided 
into  the  per/oraliui^  and  the  episcleral.  The  perforating::;  arteries 
stop  about  ,|„  inch  from  the  corneal  margin,  and  are  well  seen  in 
glaucoma ;  the  episcleral  arteries  form  a  ])ink  zone  of  straight 
parallel  vessels  {circumcorfieal zone)  not  disappearing  on  pressure, 
and  are  well  marked  in  iritis  and  keratitis ;  the  episcleral  veins  are 
dark,  dusky-looking,  often  in  limited  i)atches,  and  are  found  in 
cyclitis,  scleritis,  glaucoma,  etc.  3.  The  anterior  conjunctival 
vessels  are  superficial  branches  of  the  anterior  ciliary.  They  are 
bright  red  in  color,  found  near  the  corneal  margin,  and  indicate 
superficial  corneal  mischief. 


PHYSICAL    EXAMINATION    OF    THE.  483 

Next  examine  the  cornea,  the  depth  and  contents  of  the  an- 
terior chamber,  and  the  iris  as  to  its  color,  polish  and  pupillary 
aperture. 

The  normal  pupil  is  from  3.5  to  5  mm.  in  diameter,  circular, 
regular,  shghtly  to  the  nasal  side  of  the  centre  of  the  cornea,  and 
equal  to  and  varying  with  its  fellow  under  dififerent  degrees  of 
illumination.  The  pupil  should  contract : — on  light  being  thrown 
into  the  same  eye  {direct  light  reflex),  on  light  being  thrown  into 
the  opposite  eye  {consensual  light  reflex),  and  on  accommodation 
or  on  the  convergent  movements  of  the  eye  associated  with  ac- 
commodation {accoinmodatioji  reflex).  It  should  dilate  on  one 
or  both  eyes  being  shaded,  and  also  on  stimulation  of  a  sensory 
nerve  {sensory  reflex).  Atropine,  and  homatropine,  produce  a 
dilated  pupil  {mydriasis)  inactive  to  any  of  the  reflexes  ;  cocaine 
causes  mydriasis,  but  the  pupil  still  acts  to  the  contraction  re- 
flexes ;  and  eserine,  pilocarpine,  produce  a  contracted  pupil 
{miosis)  always  dilating  slightly  on  shading  or  on  relaxation  of 
accommodation.  The  pupil  is  influenced  by  the  blood  supply, 
and  if  there  is  congestion  of  the  iris  it  is  contracted  {congestion 
miosis) . 

(2)  Examinatio7i  with  the  ophthalmoscope. — The  ophthal- 
moscope in  its  simplest  form  consists  of  a  silvered  glass  concave 
mirror  of  about  20  centimetres  focal  length,  with  a  central  aper- 
ture {sight  hole)  of  3  miUimetres  diameter,  fitted  on  a  suitable 
handle.  If  required  for  estimating  refraction,  lenses  are  arranged 
to  pass  behind  the  sight  hole.  The  methods  of  using  it  are  di- 
vided into  {a),  direct  ^.wA  {b),  indirect,  and  are  much  easier  with 
a  dilated  pupil ;  for  this  object  homatropine  or  homatropine  and 
cocaine  should  be  used  if  possible,  {a)  To  use  the  direct 
method  the  patient  should  be  sitting  with  the  light  at  first  just 
above  and  behind  the  head,  the  observer  being  about  four  feet 
away.  Throw  the  reflection  of  the  light  from  the  ophthalmoscope- 
mirror  through  the  pupil,  and  observe  through  the  sight  hole  the 
pupillary  area  as  a  red  color  {red  reflex).  On  now  slowly  rotat- 
ing the  mirror  horizontally  and  vertically  a  shadow  is  seen  if  the 
refraction  is  abnormal  (araetropic),  and  this  shadow  moves  in  the 
same  direction  as  the  mirror  in  myopia,  and  in  the  opposite  di- 
rection in  hypermetropia  and  in  myopia  of  less  than  one  dioptre. 
{Retinoscopy.)  Approaching  closer  to  the  patient,  examine  the 
media,  and  observe  if  any  objects  other  than  retinal  vessels  and 
the  optic  disk  are  seen.  If  so,  on  telling  the  patient  to  move  his 
eye  in  different  directions,  these  objects,  which  are  usually  of  a 
dark  color,  will  float  about  if  they  are  in  the  vitreous.  The  lamp 
should  next  be  moved  on  a  level  with  the  patient's  head  and  on 
the  same  side  as  the  eye  under  examination.     On  now  bringing 


484  DISEASES   OF   REGIONS. 

the  ophthalmoscope  to  about  2  inches  from  the  patient's  cornea, 
and  at  the  same  time  relaxing  your  own  accommodation  and  tell- 
ing him  to  look  into  the  far  distance  and  to  move  his  eye  about 
as  you  direct,  inspect  the  details  of  the  fundus.  If  the  patient 
has  an  error  of  refraction  it  is  necessary  to  correct  it  by  a  suitable 
lens  behind  the  sight  hole.  Now  place  a  lens  of  nine  dioptres 
behind  the  sight  hole  to  investigate  the  vitreous  and  the  posterior 
part  of  the  lens,  and  one  of  twenty  dioptres  to  see  the  cornea, 
anterior  chamber,  iris  and  anterior  part  of  the  lens. 

{d)  The  /;/c//;rr/ method  is  perhaps  easier  to  a  beginner,  and 
gives  an  extensive  and  rapid  view  of  the  fundus,  but  is  not  so  ac- 
curate as  to  minute  details.  At  a  distance  of  18  inches  look 
through  the  sight  hole,  your  right  eye  at  the  patient's  right  eye, 
and  vice  versa,  telling  him  to  look  into  the  far  distance  (to  relax 
his  accommodation)  in  the  same  direction  as  the  fingers  holding 
the  ophthalmoscope  if  the  disk  is  to  be  examined,  or  at  the  sight 
hole  if  the  yellow  spot  region  is  to  be  investigated.  Atter  obtain- 
ing the  red  reflex,  hold  a  lens  of  about  2^  inches  focal  length  be- 
tween you  and  the  patient  and  at  about  2}4  inches  from  the 
patient's  eye  ;  an  inverted  view  of  the  fundus  will  be  thus  obtained. 

The  following  are  the  chief  details  to  be  observed  in  the  normal 
fundus.  The  optic  disk  is  grayish-pink,  lighter  than  the  rest  of  the 
fundus,  and  nearly  circular  in  shape  ;  its  centre  is  sometimes 
stippled  {lamina  cribj-osa),  and  often  depressed  {physiological 
cup)  with  the  retinal  vessels  dipping  into  it.  The  periphery  of 
the  disk  is  usually  lighter  in  color  {scleral  ring)  and  often  bor- 
dered in  part  by  pigment.  Occasionally  an  opaque  white  striated 
patch,  radiating  from  the  edge  of  the  disk,  is  seen  with  its  margin 
gradually  thinning  out  {opaque  nerve  fibres').  The  rest  of  the 
fundus  is  bright  red,  with  the  retinal  vessels  on  it ;  sometimes  the 
choroidal  vessels  may  be  seen  plainly  as  a  network  and  of  a 
lighter  color  than  the  retinal  vessels.  At  the  yellow  spot  the 
choroidal  red  is  generally  deeper  in  color  and  there  are  no  blood- 
vessels. 'I'he  retinal  arteries  are  as  a  rule  smaller  and  lighter  in 
color  than  the  veins  ;  both  usually  divide  at  a  short  distance  from 
the  disk  into  superior  and  inferior  temporal  and  nasal  branches. 
The  retinal  veins  can  often  be  seen  to  pulsate  even  in  health,  and 
by  pressing  on  the  eyeball  with  the  finger  the  arteries  can  gen- 
erally be  made  to  pulsate. 

(3)  Acuteness  of  vision. — Snellen's  test-types  are  those  usually 
employed  for  testing  vision,  and  are  constructed  so  as  to  be  seen 
under  the  smallest  visual  angle  (5  minutes).  Place  the  patient 
at  6  metres  from  the  distant  type,  and  if  his  distant  vision  is 
normal,  he  ought  to  read  the  smallest  letters,  numbered  6  on  the 
types.     His  vision  is  then  called  ;;,  or  1.     If  he  only  reads  the 


MEIBOMIAN   CYST.  485 

top  letter  it  is  ,/\,,  or  tV,  and  so  on.  If  the  patient  is  under  45 
give  him  the  reading  types  arranged  on  the  same  plan,  and  find 
out  the  smallest  he  can  read,  and  at  what  distance,  thus  finding 
his  near  point  and  accommodation.  If  he  is  too  blind  to  see  the 
type  hold  your  fingers  before  his  eye,  and  measure  the  greatest 
distance  at  which  he  can  count  them.  If  he  is  unable  to  see  the 
fingers,  shade  his  eye,  and  throwing  light  into  it,  see  if  he  has 
perception  of  light.  If  a  patient  has  only  perception  of  light,  the 
observer  should,  by  means  of  the  ophthalmoscope-mirror  in  a 
dark  room,  throw  light  on  to  the  different  parts  of  his  fundus  to 
see  if  all  are  equally  light-percipient  {^projection) . 

The  fields  of  vision  may  now  be  mapped  out  roughly  by  the 
fingers,  or  by  the  perimeter,  for  white  and  colors.  Any  spots  of 
the  field  in  which  the  object  used  is  not  seen  are  called  scotomata. 
The  colo7'  vision  is  usually  estimated  by  colored  wools. 

Intra  ocular  tension  may  be  estimated  by  instruments  called 
tonometers,  or  by  the  fingers  ;  the  latter  is  the  usual  way,  and  is 
effected  by  directing  the  patient  to  look  down  on  the  ground,  and 
then  palpating  the  eyeball  through  the  upper  lid  with  both  index 
fingers.  Certain  degrees  of  tension  have  been  recognized,  the 
firm,  tense,  semifluctuating  feeling  of  the  normal  eye  being  taken 
as  the  mean  i^Tn')  ;  these  are  denoted  according  to  the  degree  of 
increased  tension  +  I, -|- 2, +3,  or  of  diminished  tension  —  i,  —  2, 

— 3- 

I.  Diseases  of  the  eyelids  and  lachrymal  apparatus. 

Ciliary  Blepharitis  ( Tinea  Tarsi)  is  the  most  common  in- 
flammatory affection  of  the  lids  ;  it  is  usually  chronic,  and  occurs 
especially  in  ill-fed,  dirty,  hypermetropic,  or  strumous  children. 
The  symptoms  are  redness  of  the  ciliary  border  of  the  lids,  and 
either  an  eczematous  condition  of  the  border,  or  more  commonly 
inflammation  and  vesication  of  the  hair  follicles,  with  stunted  and 
misplaced  eye-lashes,  followed  in  bad  cases  by  scarring  of  the 
edge  of  the  hd,  and  slight  eversion.  The  best  treatment  is  an 
alkaline  lotion,  as  sodium  bicarbonate,  and  a  weak  mercurial  oint- 
ment applied  along  the  edges  of  the  lids  night  and  morning ;  in 
severe  cases  removal  of  the  lashes  and  painting  the  borders  of  the 
lids  with  silver  nitrate  solution  is  advisable. 

The  eyelashes  may  be  the  seat  of  the  pediculus  pubis,  giving 
rise  to  a  condition  which  may  simulate  ciliary  blepharitis  if  there 
has  been  much  irritation. 

Meibomian  Cyst  {chalazion)  is  the  most  common  form  of 
tarsal  tumor,  and  is  due  to  chronic  inflammation  of  the  fundus 
of  a  Meibomian  gland.  It  occurs  as  a  small,  hard,  painless  swell- 
ing, with  the  skin  of  the  lid  freely  movable  over  it.     On  the  con- 


486  DISEASES   OF   REGIONS. 

junctival  surface  of  the  lid  there  is  usually  a  bluish-grey  dis- 
colored spot,  due  to  thinning  of  the  tissues.  A  cnicial  incision 
should  be  made  through  this  spot,  and  the  semi-fluid  contents 
evacuated  by  pressure  or  by  a  small  spoon.  These  cysts  have  no 
wall,  are  generally  multiple,  most  common  in  young  adults,  and 
are  very  prone  to  suppurate. 

Site  {hordeolum)  is  a  localized  inflammation  of  the  cellular 
tissue  of  the  lid,  usually  about  an  eyelash,  but  sometimes  in  con- 
nection with  the  duct  of  a  Meibomian  gland.  It  gives  rise  to 
throbbing  pain,  and  swelling  and  oedema  of  the  lid  ;  it  is  usually 
succeeded  by  others,  and  is  due  to  some  derangement  of  the  gen- 
eral health  or  error  of  refraction.  It  quickly  disappears  on  evac- 
uating the  pus  if  present,  or  on  pulling  out  the  faulty  lash. 

Symblepharon,  or  adherence  of  the  palpebral  conjunctiva  to 
the  ocular  conjunctiva  or  cornea,  may  occur  owing  to  inflamma- 
tion following  burns,  wounds,  and  ulcerations. 

Congenital  Malformations  of  the  lids  are,  ptosis  (drooping  of 
the  upper  lid),  epicanthus  (a  fold  of  skin  stretching  across  the  inner 
canthus  and  concealing  the  caruncle),  and  coloboina  (a  deficiency 
of  part  of  the  lid). 

The  Muscular  Syslem  of  the  Lids  may  be  affected  by  sj^asm 
of  the  orbicularis  palpebrarum  {blepharospasm),  paralysis  of  the 
orbicularis  giving  rise  to  inability  to  close  the  eye,  and  paralysis 
of  the  levator  palpebrse  producing  ptosis. 

Inversion  of  the  Eyelid  {entropion)  is  produced  by  some 
affection  of  the  conjunctiva  or  tarsus,  or  by  spasm  of  the  palpebral 
portion  of  the  orbicularis  muscle.  The  most  frecjuent  result  of 
entropion  is  trichiasis  (turning  in  of  the  lashes)  giving  rise  to 
pannus,  ulceration  of  the  cornea,  etc. 

Evfrsion  of  'jhe  Eyelid  {ectropion)  is  due  to  atrophy  of  the 
palpebral  portion  of  the  orbicularis  muscle,  to  swelling  of  the  con- 
junctiva, or  to  cicatricial  contraction.  Numerous  operations  have 
been  planned  for  ectropion  and  entropion  and  the  consequent 
faulty  position  of  the  lashes. 

The  Lachrymal  Apparatus  consists  of  the  lachrymal  gland  and 
its  ducts  situated  at  the  upper  and  external  angle  of  the  orbit,  and 
the  drainage  system,  which  includes  the  puncta,  canaliculi, 
lachrymal  sac  and  nasal  duct.  The  lachrymal  gland  may  be  the 
seat  of  acute  or  chronic  inflammation,  and  may  also  be  affected 
by  hypertrophy,  or  sarcoma.  The  chief  lachrymal  troubles,  how- 
ever, are  associated  with  the  drainage  system,  and  the  most 
marked  symptom  is  that  of  watery  eye  {epiphora).  The  puncta 
may  be  everted  or  inverted  by  changes  in  the  lid,  or  stenosed 
from  inflammation,  etc.  The  canaliculi  may  be  narrowed  by  in- 
flammatory changes  or  cicatrization  after  injury,  or  obstructed  by 


PURULENT   CONJUNCIIVITIS.  487 

cilia,  concretions,  etc.  The  entrance  of  the  canaliculi  into  the 
sac  is  a  very  common  place  for  stenosis.  The  lachrymal  sac  may 
be  affected  by  inflammation  spreading  from  the  conjunctival  or 
nasal  mucous  membrane.  This  may  be  accompanied  by  stricture 
of  the  nasal  duct,  and  sometimes  gives  rise  to  a  collection  of 
mucus  in  the  sac  {jnucocele),  and  presents  as  a  fluctuating  swell- 
ing near  the  inner  canthus.  On  pressing  over  the  swelling  the 
fluid  can  usually  be  forced  out  through  the  puncta.  A  lachrymal 
abscess  often  follows  a  mucocele ;  the  symptoms  are  then  tense 
swelling  and  redness  of  the  integument  in  the  neighborhood  of 
the  lachrymal  sac.  The  treatment  for  stenosis  of  the  puncta  or 
canalicuH  is  to  employ  probes  or  electrolysis,  and  if  these  methods 
fail,  to  slit  up  the  lower  canaliculus  by  a  Weber's  knife,  removing 
a  piece  of  the  conjunctiva  from  the  inner  side  of  the  incision  with 
scissors.  For  stenosis  of  the  nasal  duct  probes  should  be  used  to 
dilate  it,  and  in  many  cases  the  use  of  styles  for  some  time  is  ad- 
visable. In  acute  inflammation  of  the  sac  an  incision  should  be 
made  from  the  outside  through  the  swelling,  or  the  lower  canali- 
culus should  be  slit  up,  and  the  pus,  if  found,  evacuated  that  way  ; 
the  sac  should  afterwards  be  syringed  with  antiseptic  or  astringent 
solutions. 

II.  Diseases  of  the  Conjunctiva. 

Conjunctivitis  (^Ophthalmia) ,  or  inflammation  of  the  con- 
junctiva, is  characterized  by  a  feeling  of  grittiness,  heat,  and 
heaviness  of  the  lids,  which  tend  to  stick  together,  especially  at 
night,  injection  of,  and  small  haemorrhages  from,  the  posterior 
conjunctival  vessels,  and  generally  discharge  from  the  eye. 

1.  Catarrhal  {mitco-pi/mlent)  Conjunctivitis  may  be  acute 
or  chronic  ;  it  presents  the  usual  symptoms  of  conjunctivitis  (see 
above),  and  is  often  accompanied  by  more  or  less  muco-purulent 
discharge.  It  occurs  in  epidemics,  and  if  there  is  much  dis- 
charge, is  contagious.  There  is  often  marked  enlargement  of  the 
conjunctival  follicles,  especially  of  the  lower  lid  {follicular  con- 
junctivitis).    Occasionally  the  discharge  is  more  plastic  in  nature, 

adhering  to  the  lids  {pseudo-membraneous  conjunctivitis).  It  is 
best  treated  by  slight  astringents  or  antiseptic  lotions,  and  by 
ointments  placed  along  the  edges  of  the  lids  to  prevent  their 
sticking  together.  In  chronic  cases  the  refraction  should  always 
be  tested,  as  refraction- errors,  especially  hypermetropia,  may  pro- 
duce this  condition. 

2.  Purulent  Conjunctivitis  is  an  acute  affection  characterized 
by  the  severity  and  rapidity  of  its  onset.  It  is  microbic  in  origin, 
and  the  specific  organism  is  frequently  the  gonococcus.  It  may 
be  conveniently  divided  into  two  classes  : 


488  DISEASES   OF   REGIONS. 

I.  Adult  Puj-ulent  Conjunctivitis  {^Gonorrhceal  Ophthabnia), 
the  more  serious  affection,  is  due  to  actual  contagion  with  the 
vims,  and  usually  first  affects  only  one  eye.  The  period  of  incu- 
bation may  be  only  a  few  hours.  The  lids  at  first  are  red  and 
cedematous  ;  the  conjunctiva  is  much  swollen  and  infiltrated  with 
serum  {cJiemosis),  and  the  discharge  is  serous  in  nature.  After 
two  or  three  days  the  serous  discharge  changes  to  a  very  copious 
discharge  of  thick  pus.  The  great  danger,  if  the  condition  is  not 
soon  reUeved  by  energetic  treatment,  is  infiltration  of  the  cornea, 
giving  rise  to  a  perforating  ulcer  and  subsequent  loss  of  the  eye 
for  useful  vision. 

II.  Infantile  Purulent  Conjunctivitis  {Ophthalmia  neonatorum') 
occurs  in  new-born  children,  generally  on  the  third  day  after  birth. 
It.  affects  as  a  rule  both  eyes,  and  is  due  to  inoculation  from  the 
vaginal  discharges  of  the  mother ;  to  avoid  this  risk  every  child's 
eyes  should  be  thoroughly  washed  immediately  after  birth  with 
an  antiseptic  solution.  The  symptoms  are  similar  but  not  so 
severe  as  in  the  adult,  and  the  cornea  is  not  so  likely  to  become 
involved.  The  chief  complications  are  corneal  ulcers,  leukoma 
adherens,  anterior  polar  cataract,  and  panophthalmitis  followed 
by  shrinking  of  the  globe. 

The  treatment  must  be  directed  chiefly  to  washing  away  the  dis- 
charge. For  this  purpose  the  eye  should  be  thoroughly  syringed 
or  washed  every  hour,  day  and  night,  with  a  lotion  of  corrosive 
sublimate  (i  to  6,000).  At  the  same  time  the  lid  should  be 
everted  if  possible  and  painted  with  silver  nitrate  solution  (grs. 
X,  to  5J.)  once  a  day,  and,  if  practicable,  ice-pads  applied  to  the 
lids.  This  treatment  should  be  continued  as  long  as  the  discharge 
continues  purulent.  Ulceration  of  the  cornea  should  be  treated 
energetically  by  the  actual  cautery  or  sohd  nitrate  of  silver.  If 
only  one  eye  is  affected,  the  rule  in  the  adult,  the  opposite  eye 
should  be  covered  if  possible  by  a  watch-glass  shade  to  prevent 
noculation. 

3.  Memhrani'.ous  {(liphtheritic)  cONjuNcrivrns  is  the  most 
serious  and  virulent  form  of  ophthalmia,  and  an  eye  may  be  de- 
stroyed by  it  in  twenty-four  hours.  It  is  marked  by  great  pain 
and  excessive  brawniness  and  stiffness  of  the  lids,  owing  to  the 
plastic  infiltration  of  the  mucous  and  submucous  surfaces.  The 
palpebral  conjunctiva  is  covered  by  a  smooth  grey  membrane,  and 
if  this  is  stripped  off,  the  surface  still  remains  grey.  The  mem- 
brane lasts  from  6  to  lo  days,  and  is  then  followed  by  purulent 
conjunctivitis.  Treatment. — At  first  antiseptic  lotions  and  warm 
fomentations,  and  then  the  usual  treatment  for  ])urulent  conjunc- 
tivitis. In  two  cases  lately  under  my  care  the  membrane  rapidly 
disappeared,  without  being  followed  by  purulent  conjunctivitis, 
after  the  subcutaneous  injection  of  diphtheric  anti-toxin. 


PTERYGIUM.  489 

4.  Granular  conjunctivitis  {Trachoma)  derives  its  name  from 
the  presence  on  the  palpebral  conjunctiva,  especially  near  the 
fornix  of  the  upper  lid,  of  greyish  raised  bodies  about  the  size  of  a 
pin's  head.  It  may  be  acute  or  chronic,  and  occurs  at  all  ages 
except  in  very  young  children.  It  is  especially  common  in  those 
subjected  to  bad  hygienic  surroundings ;  hence  its  frequency  in 
insanitary  schools,  marshy  districts,  and  overcrowded  camps. 
The  acute  form  is  rare  in  England  and  is  accompanied  usually  by 
a  muco-purulent  discharge  which  generally  absorbs  the  granula- 
tions and  so  cures  the  disease.  In  the  chronic  form  the  symptoms 
are  a  heavy  look  of  the  lids,  irritable  eyes,  and  at  times  a  muco- 
purulent discharge.  The  muco-purulent  discharge  depends  more 
upon  the  condition  of  the  conjunctiva  than  on  the  presence  of 
the  granulations.  The  disease  is  probably  only  contagious  during 
the  continuance  of  the  discharge.  The  granulations  often  affect 
the  submucous  tissue,  giving  rise  to  scarring.  Pathology. — There 
are  two  views  as  to  the  nature  of  the  granules  :  i.  That  they  are 
due  to  hypertrophy  of  the  lymph-follicles  of  the  conjunctiva  ;  and, 
2,  that  they  are  new  growths.  The  disease  is  beUeved  by  some 
to  depend  upon  the  presence  of  a  specific  micro-organism.  It 
may  be  complicated  by  pannus,  ulcers  of  the  cornea,  entropion, 
trichiasis,  etc.  Treatment. — In  the  acute  form  antiseptic  lotions 
should  be  employed.  In  the  chronic  form,  with  muco-purulent 
discharge,  paint  the  inside  of  the  Hds  once  a  day  with  silver 
nitrate  solution  (grs.  x.  to  ,^j.),  and  order  an  astringent  lotion,  as 
zinz  sulphate  (grs.  ii.  to  .?j.),  to  be  dropped  into  the  eye  two  or 
three  times  a  day.  If  there  is  no  discharge,  touch  the  granula- 
tions lightly  two  or  three  times  a  week  with  a  crystal  of  copper 
sulphate.  During  the  discharge  stage  the  patient  should  be 
isolated. 

5.  Phlyctenular  conjunctivitis  is  characterized  by  the  pres- 
ence on  the  ocular  conjunctiva  or  on  the  anterior  surface  of  the 
cornea  of  one  or  more  papules  or  pustules  surrounded  by  a  limited 
vascular  zone.  It  is  extremely  common  in  young  children,  es- 
pecially if  strumous.  Photophobia  or  Hd-spasm  may  be  present. 
The  t7-eatment  is  chiefly  dietetic,  with  the  local  application  of 
yellow  mercuric  oxide  ointment. 

Pinguecula  is  a  yellowish  elevation,  not  containing  fat,  of 
thickened  conjunctiva  and  subconjunctival  tissue,  near  the  inner 
or  outer  edge  of  the  cornea. 

Pterygium  is  a  triangular  thickened  piece  of  the  ocular  con- 
junctiva, with  its  apex  at  the  margin  of  or  on  the  cornea.  It  is 
especially  found  on  people  who  have  been  in  the  tropics.  If  it 
invades  the  cornea  it  may  be  dissected  off  and  the  apex  stitched 
back  on  the  conjunctiva. 


490  DISEASES   OF   REGIONS. 

Wounds  of  the  conjunctiva  heal  well,  and  if  extensive  ought  to 
be  stitched  up. 

III.  Diseases  of  the  coj-nea  and  sclerotic. 

Keratitis,  or  inflammation  of  the  cornea,  is  characterized,  as  a 
rule,  by  pain,  photophobia,  lachrymation,  impairment  of  vision, 
pink  circumcorneal  vascular  zone,  and  want  of  natural  trans- 
parency of  the  cornea.  It  may  be  divided  by  its  position  into  i, 
superficial ;  2,  interstitial ;  and  3,  posterior  or  punctate. 

1.  Superficial  keratitis  is  usually  produced  by  irritation  due 
to  roughness  or  insufficient  protection  of  the  lids.  The  condition 
is  often  vascular  {pannus).  A  very  painful  form  is  accompanied 
by  numerous  small  vesicles  {herpes  of  the  cornea).  The  treatment 
consists  in  the  removal  of  the  irritant,  and  in  the  application  of 
sedative  lotions  of  opium,  belladonna,  etc.  In  obstinate  cases  of 
pannus  the  operation  of  pcritomy  (removal  of  a  ring  of  con- 
junctiva round  the  corneal  periphery  so  as  to  cut  off  the  super- 
ficial blood  supply  to  the  cornea)  may  be  performed. 

Corneal  Ulcer  a'-,  a  loss  of  substance  due  to  limited  inflammation 
of  the  corneal  tissue.  It  is  described  here  under  superficial 
keratitis  because  it  usually  begins  in  the  superficial  or  epithelial 
part  of  the  cornea.  Sometimes  from  the  commencement  it  af- 
fects the  corneal  tissue  proper,  and  is  then  generally  produced  by 
a  limited  collection  of  pus  in  the  lamell?e  of  the  cornea  {abscess 
or  onyx).  A  corneal  ulcer  may  be  {a)  simple,  or  {I?)  infective, 
and  in  either  case  may  be  central  or  peripheral,  acute  or  chronic. 

{a)  The  simple  ulcer  may  be  due  to  an  abrasion  of  the  cornea, 
a  phlyctenule,  etc.,  and  is  best  treated  when  acute  by  atropine 
drops,  unless  it  be  deep  and  peripheral,  when  eserine  or  pilocar- 
pine drops  are  to  be  preferred.  When  chronic,  an  ointment  of 
yellow  mercuric  oxide  (gr.  ij. — xv.  to  vaseline  ^j.)  should  be 
placed  in  the  eye  once  or  twice  a  day,  and  massage  employed  to 
the  surface  of  the  closed  lid. 

{b)  The  infective  ulcer  tends  to  spread  rajjidly  at  its  edges  and 
also  in  depth ;  it  is  often  accompanied  by  hypopyon  (pus  in  the 
anterior  chamber)  and  then  is  generally  microbic  in  origin.  The 
best  treatment  is  the  actual  cautery  or  solid  nitrate  of  silver  ap- 
plied to  the  edges  and  base ;  the  evacuation  of  the  pus  in  an 
adult  by  ta]jping  the  anterior  chamber  from  below  ;  and  the  local 
application  of  belladonna  or  atropine. 

2.  Intersti'iiai,  keratitis  is  usually  associated  with  congenital 
syphilis,  sometimes  with  struma,  and  occasionally  with  acquired 
syphilis.  The  whole  cornea  undergoes  a  subacute  or  chronic  in- 
flammation, and  at  first  looks  steamy  and  then  patchy  and  like 


FOREIGN    BODIES.  49  I 

ground  glass ;  the  patches  usually  become  vascular  {salmon 
patches^,  but  there  is  no  tendency  as  a  rule  to  superficial  ulcer- 
ation or  suppuration.  After  some  months  the  eye  begins  to  clear 
up  under  treatment,  even  in  very  bad  and  apparently  hopeless 
cases.  Though  as  a  rule  one  eye  is  attacked  first,  the  other  after 
a  few  weeks  or  months  generally  becomes  affected.  The  usual 
age  is  between  five  and  sixteen.  The  attendant  complications  are 
iritis,  secondary  glaucoma,  uveitis,  and  in  very  bad  cases  shrink- 
ing of  the  eyeball.  After  an  attack  there  are  to  be  found  gen- 
erally nebulae  in  the  cornea  and  always  the  remains,  at  the  corneal 
periphery,  of  the  vessels  of  inflammation.  The  treatment  is 
usually  the  administration  of  small  doses  of  mercury  over  a  long 
period,  or  iron  tonics,  and  locally  atropine  and  yellow  oxide  of 
mercury  ointment. 

3.  Keratitis  punctata  is  probably  never  present  without  dis- 
ease of  the  uveal  tract  (page  492).  It  is  characterized  by  the 
presence  of  dots  of  different  sizes  on  the  epithelium  of  Descemet's 
membrane.  These  are  generally  arranged  in  the  lower  half  of  the 
cornea  in  the  shape  of  a  conical  bullet  with  the  apex  upwards. 
The  dots  may  be  proliferations  of  the  posterior  corneal  epithelial 
cells,  or  granules,  etc.,  deposited  on  the  epithelium. 

The  results  of  keratitis  are  often  to  be  found  in  the  corneal 
tissue  as  small  branching  lines  (remains  of  vessels),  greyish 
opacities  {nebulce),  and  dense  opaque  white  patches  {leiikomata). 
The  use  of  lead  lotion  in  keratitis  is  especially  prone  to  give  rise 
to  leukomata,  and  should  therefore  never  be  used  in  this  disease. 
In  cases  of  perforating  ulcer,  the  iris  may  become  adherent  to  the 
cornea,  a  condition  known  as  anterior  synechia,  or  if  the  corneal 
scar  is  white,  as  leukoma  adherens.  The  other  results  which  may 
occur  are  conical  cornea,  and  bulging  of  the  cornea  and  sclerotic 
{anterior  staphyloma') . 

Conical  cornea  (keratoconus)  is  a  bulging  of  the  central  por- 
tion of  the  cornea.  It  generally  occurs  in  females,  and  is  due  to 
defective  nutrition  of  the  corneal  tissue.  It  may  follow  an  ulcer, 
especially  if  central.  Operative  procedures,  as  iridectomy,  tre- 
phining the  cornea,  etc.,  rarely  do  any  good,  and  the  same  may 
usually  be  said  for  concave  and  stenopeic  glasses. 

Foreign  bodies  on  the  cornea  should  be  removed  as  soon  as 
possible.  Anaesthesia  of  the  cornea  should  first  be  obtained  by 
dropping  4%  cocaine  solution  three  times  into  the  eye  at  inter- 
vals of  five  minutes.  The  patient  being  placed  on  a  chair  facing 
the  light,  the  operator  stands  behind  the  patient  and  with  the 
fingers  of  the  left  hand  separates  the  lids,  at  the  same  time  press- 
ing on  the  eyeball  to  steady  it.  Then  with  a  spud  or  needle  held 
in  the  right  hand  the  foreign  body  should  be  Ufted  off  or  picked 
out  of  the  cornea. 


492  DISEASES   OF   REGIONS. 

ScLERiTis  {episcleritis^  or  inflammation  of  the  scleral  tissue,  is 
accompanied  by  a  circumscribed  reddish-purple  patch  of  vascular 
congestion  about  2  to  3  mm.  from  the  corneal  margin,  generally 
on  the  outer  side.  It  lasts  as  a  rule  for  some  months,  and  often 
relapses ;  the  pain  and  tenderness  vary  much  in  intensity,  and  in 
severe  cases  keratitis  and  iritis  may  be  present.  It  is  more  com- 
mon in  women  than  men,  and  affects  especially  those  of  the  rheu- 
matic and  strumous  diathesis,  or  patients  with  a  syphihtic  taint. 
The  best  modes  of  ireat»tent  are  warm  fomentations  of  opium, 
leeches,  massage,  belladonna  and  atropine  if  iritis  is  suspected, 
and  general  constitutional  remedies. 

Wounds  of  this  region  may  be  divided  into  id)  corneal,  {b^ 
scleral,  and  {c)  sclero-corneal.  (^)  Corneal  wounds,  unless 
implicating  the  lens  or  iris,  generally  heal  quickly,  {b')  Scleral 
liwunds  more  than  y{  inch  behind  the  sclero-corneal  junction,  if 
small  and  unaccompanied  by  the  presence  of  a  foreign  body  in 
the  eye,  may  be  stitched  up,  or  the  conjunctiva  stitched  over  them, 
and  then  treated  by  ice-pads  to  allay  inflammation,  (r)  Sclero- 
corneal  wounds  are  the  most  dangerous,  owing  to  the  great  risk 
of  sympathetic  inflammation,  and  demand  great  judgment  in  sav- 
ing the  eye  ;  in  most  cases  the  eye  ought  to  be  excised,  especially 
if  the  lens  is  injured. 

IV.  Diseases  of  the  uveal  tract. 

The  UVEAL  traci'  comprises  the  iris,  ciliary  body  and  choroid, 
and  though  disease  may  be  limited  to  one  part,  there  is  always  a 
tendency  for  it  to  spread  through  the  whole  tract. 

Iri'iis  or  iNFLAMMAiioN  OF  THE  IRIS  may  be  acute,  subacute  or 
chronic.  The  usual  symptoms  of  a  case  of  acute  or  subacute  iritis 
are — pain  and  tenderness  along  the  ophthalmic  division  of  the  fifth 
nerve,  dimness  of  sight,  lachrymation,  injection  of  the  episcleral 
vessels  giving  rise  to  a  pink  circumcorneal  zone,  and  occasionally 
photophobia.  The  iris  is  dull  and  discolored,  e.  .<,'•.,  a  blue  iris 
becomes  green,  the  pupil-  is  sluggish,  contracted,  generally  irreg- 
ular owing  to  adhesions  to  the  anterior  capsule  of  the  lens  {pos- 
terior synechice),  and  acts  badly  or  not  at  all  to  atropine.  In 
chronic  iritis  there  may  be  no  symptoms  except  irregularity  of 
pupil,  dimness  of  vision,  and  at  times  pain.  Iritis  is  especially 
likely  to  occur  in- patients  suffering  from  syphilis,  rheumatism,  or 
gout ;  it  may  also  have  a  traumatic  origin,  or  be  secondary  to 
inflammations  of  the  cornea,  sclerotic,  or  the  other  parts  of  the 
uveal  tract.  The  iritis  associated  with  syphilis  is  often  symmetri- 
cal, and  generally  accomj)anied  by  great  effusion  of  lymph  in  the 
neighborhood  of  the  pupil,  but  in  the  secondary  stage  of  this  dis- 


IRIDECTOMY.  493 

ease  the  symptom  may  be  absent.  Iritis  in  rhaimatic  patients  is 
usually  very  painful,  and  differs  as  a  rule  from  the  syphilitic  vari- 
ety in  its  great  tendency  to  recur.  It  is  especially  liable  to  attack 
those  of  the  rheumatic  diathesis  if  suffering  from  prolonged  gon- 
orrhoea! discharge.  In  gou/y  subjects  there  may  be  a  very  insidi- 
ous form  {quiet  iritis).  The  local  treatment  is  first  directed  to 
obtaining  dilatation  of  the  pupil  by  atropine  or  atropine  and 
cocaine  combined  ;  if  there  is  much  congestion  of  the  conjunc- 
tival vessels  and  pain,  it  is  well  to  apply  one  or  two  leeches  or  a 
small  blister  to  the  temporal  region  about  one  inch  from  the  ex- 
ternal canthus.  The  general  treatment  is  that  applicable  to  the 
diathesis  of  the  patient,  but  a  mild  course  of  mercury  is  by  some 
always  prescribed  in  acute  iritis. 

The  chief  trauimatic  affections  of  the  iris  are  blood  in  the 
anterior  chamber  {hyphoenia) ,  mydriasis  (due  to  paralysis  of  the 
sphincter  pupillse),  tremulous  iris  (generally  due  to  dislocation  of 
the  lens),  rupture  of  the  ciliary  border  of  the  iris  {coretlialysis),  a 
rent  in  the  pupillary  border,  and  prolapse  of  the  iris  after  a  per- 
forating wound. 

The  congenital  abnormalities  are  difference  in  color  in  both 
irides,  irregularity  in  shape  and  position  of  pupil,  multiple  pupils 
{polycoria),  remains  of  pupillary  membrane,  deficiency  of  part  of 
iris    {coloboma),   and   absence   of    iris 
{iri(lej'emia) .     In  coloboma  the  defic-  ^^'^■ 

iency  is  generally  downwards  and  in- 
wards, and  is  often  combined  with  a 
similar  condition  of  the  choroid. 

Iridectomy. — This  operation  may  be      ^I^^^^J^ 
performed  {a)  to  improve  the  sight  in 

cases  of  corneal  opacity^  anterior  polar  Spring  eye-specuium. 

cataract  and  lamellar  cataract,  {I?)  as  a 
remedial  measure  in  glaucoma,  relapsing  iritis,  and  complete  pos- 
terior synechia,  and  (<:)  in  cataract  extraction. 

Operation. — Place  the  patient  in  the  recumbent  posture  and 
induce  general  ansesthesia,  preferably  by  chloroform,  or  local 
ansesthesia  by  means  of  cocaine  (4  %),  Standing  behind  the 
patient's  head,  introduce  the  spring  speculum  (Fig.  219)  ;  fix  the 
conjunctiva  near  the  cornea  with  fixation-forceps  opposite  the 
place  selected  for  the  coloboma.  Pass  the  keratome  by  pressure 
perpendicularly  through  the  cornea  (Fig.  220),  and  then  lowering 
its  handle  press  the  blade  into  the  anterior  chamber  parallel  to 
the  iris,  now  lowering  the  handle  still  more  till  the  point  nearly 
touches  the  posterior  surface  of  the  cornea,  and  then  slowly  with- 
draw the  keratome.  Give  the  fixation  forceps  to  an  assistant  to 
gently  depress  the  eye ;  pass  through  the  wound  the  iridectomy 


494 


DISEASES    OF    REGIONS. 


Fig.  220. 


forceps  closed  with  the  points  directed  towards  the  posterior  sur- 
face of  the  cornea,  open  the  forceps,  seize  the  pupillar}'  border  of 
the  iris,  slowly  draw  it  out,  and  snip  it  off  with  the  scissors  either 
parallel  to  the  wound,  or  at  right  angles  to  the  wound  across  the 
cornea.  Carefully  return  the  edges  of  the  coloboma  with  a  curette 
(Fig.  221),  and  bandage  up  the  eye.    In  iridectomy  for  glaucoma 

it  is  usual  to  have  a  large  corneal 
incision  (some  operators  preferring 
a  Graefe's  knife),  and  to  remove 
the  iris  up  to  the  ciliary  border. 

Cyclitis,  or  inflammation  of  the 
ciliary  body,  rarely  occurs  without 
other  parts  of  the  uveal  tract  being 
involved.  The  symptoms  are  cir- 
cumcorneal  zone  of  redness,  pain 
and  tenderness  in  the  ciliary  region, 
pain  on  accommodating,  and  often 
hypopyon  and  vitreous  opacities. 
It  is  best  treated  by  atropine  and 
leeches. 

Ckoroiditis,  except  as  part  of  a 
more  general  mflammation,  is  rarely 
accompanied  by  external  signs  or 
severe    pain.     Ophthalmoscopically 
there  may  be,  if  recent,  soft  yellow- 
ish-white exudation  patches  either 
at  the  yellow  spot  or  elsewhere  ;  these  patches  on  clearing  up 
leave  as  a  rule  atrophy  of  the   choroid,  showing  the  sclerotic 
through,  and  the  edges  bordered   by  disturbances  of  pigment. 
'J"he  atrophic  patches  may  be  ringed,  djffused,  or  punctate,  and 
if  due  to  haemorrhage  from  the  choroidal  vessels  are  generally 
large  and  deeply  pigmented.     I'he  retinal  vessels  always  pass  over 
these  patches  of  choroiditis.     Vision  is  as  a  rule  affected,  but  not 
always.     The  usual  causes  are  syphilis   (acquired  and  congeni- 
tal), myopia,  tubercle  and  hasmor- 
Fir,.  221.  rhages.     In  syphilitic  cases  mer- 

curial   treatment    should   be  con- 
tinued for  a  lengthened  period. 
Curette.  UvEi'iis,  or  general  inflammation 

of  the  uveal  tract,  commonly  starts 
in  the  ciliary  body,  and  is  characterized  by  the  chief  symptoms 
of  iritis,  cyclitis,  and  choroiditis.  It  may  be  divided  into  (i) 
purulent,  and  (2)  plastic. 

I.   I'URULENT  uvKi'Jls  { pa iiophthti/i/iitis)  has  usually  a  traumatic 
origin,  but  may  occur  in  ijya:;mia  and  in  old  blind  eyes.     The 


Showing  speculum  in  eye,  fixation-for- 
ceps in  position,  and  the  keratome 
passed  into  the  anterior  chamber  in 
the  operation  of  iridectomy  down- 
wards and  inwards. 


PLASTIC   UVEITIS.  495 

symptoms  are  extreme  pain,  acute  congestion  and  oedema  of  the 
lids  and  conjunctiva,  and  after  a  few  days,  if  the  media  are  trans- 
parent enough,  a  yellowish  reflex,  due,  as  a  rule,  to  suppuration 
in  the  vitreous.  The  usual  course  is  for  the  inflammation  to  affect 
the  whole  interior  of  the  eye,  and  afterwards  the  extrinsic  mus- 
cles and  Tenon's  capsule.  The  treatment  is  either  immediate 
enucleation,  or  incisions  into  the  eyeball  to  allow  free  vent  to  the 
pus.  Meningitis  has  occasionally  followed  enucleation  in  these 
cases. 

2.  Plastic  uveitis  is  characterized  by  a  great  tendency  to  de- 
position of  lymph,  and  may  be  divided  into  Acute  and  Chronic. 

(«)  Acute  plastic  uveitis  {Sympathetic  Iiifiaiiimation  or  Sympa- 
thetic Ophthalmia^  is  set  up  in  one  eye  by  morbid  changes,  usu- 
ally the  result  of  a  wound  of  the  other  eye.  The  injured  eye  is 
called  the  "exciting,"  and  the  other  the  "sympathizing  eye."  It 
occurs  usually  from  six  weeks  to  three  months  after  injury.  It  is 
preceded,  as  a  rule,  by  a  condition  known  as  "  Sympathetic  Irri- 
tation," characterized  by  lachrymation,  photophobia,  dimness  of 
sight,  oscillations  of  the  pupil  and  frontal  neuralgia.  The  symp- 
toms are  impaired  vision,  circumcorneal  zone,  keratitis  punctata, 
deep  anterior  chamber,  iritis,  papillo-retinitis,  and  opacities  in 
the  vitreous.  These  symptoms  are  followed  by  thickening  and 
vascularization  of  the  iris,  occlusion  of  the  pupil  by  lymph,  shal- 
low anterior  chamber,  diminished  tension,  shrinking  of  the 
vitreous,  detachment  of  the  retina,  etc.  The  prognosis  is  very 
unfavorable,  as  only  in  a  few  cases  the  changes  stop  short  of 
actual  loss  of  the  eye  for  useful  vision ;  and  it  must  always  be  re- 
membered that  the  sympathizing  eye  suffers  as  a  rule  more  se- 
verely than  the  exciting.  The  nature  of  the  disease  is  probably  a 
microbic  inflammation  spreading  from  the  exciting  eye  by  the 
optic  nerves  and  chiasina  to  the  sympathizing  eye.  The  treat- 
ment consists  in  confinement  to  a  dark  room,  goggles,  atropine, 
leeches  and  mercury.  If  the  exciting  eye  is  quite  blind  it  should 
be  excised,  but  if  it  has  useful  vision  it  should  be  saved. 

{i?)  Chronic  plastic  uveitis  occurs  as  a  rule  in  strumous  and 
syphilitic  patients.  The  disease  progresses  Hke  "Sympathetic 
Inflammation,"  but  is  more  chronic ;  it  usually  affects  both  eyes 
at  intervals,  and  often  passes  on  to  complete  blindness.  In 
young  children  plastic  uveitis  may  produce  a  condition  called 
''pseudo-glioma,"  which  may  be  diagnosed  as  a  rule  from  glioma 
by  discoloration  and  adhesions  of  the  iris,  minus  tension,  etc.  A 
less  severe  and  more  common  form  of  chronic  plastic  uveitis  may 
be  called  Anterior  Uveitis  {Serous  Iritis)  from  its  affecting  the 
anterior  part  of  the  uveal  tract.  It  is  characterized  by  keratitis 
punctata,  deep  anterior  chamber,  often  dilatation  of  the  pupil,  in- 


496  DISEASES   OF   REGIONS. 

creased  tension,  and  the  usual  symptoms  of  iritis  and  cyclitis,  ac- 
companied frequently  by  a  few  peripheral  choroidal  changes,  and 
small  vitreous  opacities.  It  is  generally  found  in  young  adults, 
especially  women,  and  is  often  associated  with  gout,  rheumatism, 
and  struma.  The  treatment  is  complete  rest  for  the  eyes,  and 
atropine  drops  with  careful  watching  of  tension. 

The  Uveal  tract  may  be  affected  in  any  part  by  sarcoma  (gen- 
erally melanotic),  the  usual  primary  ocular  seat  of  sarcoma  being 
the  ciliary  body  or  the  choroid. 

V.  Diseases  of  the  crystalline  lens. 

Cataract  is  the  name  applied  to  an  opacity,  complete  or 
partial,  of  the  lens,  and  is  due  to  structural  changes.  Cataracts 
may  be  divided  into  ha?-d  or  soft,  according  to  their  consistency, 
and  this  usually  depends  on  age,  as  below  thirty-five  they  are  all 
"soft."  They  are  called /r/w^:;;!' when  independent  of  any  other 
ocular  affection,  and  secondary  when  following  some  other  disease, 
as  glaucoma,  intra-ocular  tumor,  etc.  Though  all  cataracts  at 
first  are  incomplete  or  partial,  yet  it  is  advisable  to  make  a  divi- 
sion into  (i)  complete  (including  those  that  in  time  tend  to  be- 
come complete),  and  (2)  partial  (those  that  do  not,  as  a  rule, 
tend  to  become  complete). 

(i)  Complete  CATARACTS  are  usually  senile  or  hard,  and  are 
called,  according  to  their  seat  of  origin,  nuclear  or  cortical. 
Nuclear  cataracts  are  characterized  by  an  opacity  at  the  nucleus 
of  the  lens ;  they  are  often  amber  in  color  and  usually  hard,  ex- 
cept sometimes  in  diabetes ;  cortical  cataracts,  which  are  the 
more  common,  begin  as  flakes  or  streaks  radiating  from  the  axis 
of  the  lens.  Congenital  cataract  may  occur  as  a  general  opacity 
of  the  lens ;  it  is  usually  binocular,  and,  of  course,  soft.  A  com- 
plete cataract  may  degenerate  and  its  cortex  become  fluid  {Mor- 
gagjiiafi  Cataract). 

(2).  Partial  cataracts  include  {a)  lamellar,  {I))  anterior 
polar,  and  {c)  posterior  polar. 

{a)  Lamellar  {zonular)  cataract  xv,  either  congenital  or  forms 
in  early  life  ;  it  is  generally  associated  with  a  history  of  infantile 
convulsions,  and  with  a  deficiency  of  the  enamel  of  the  teeth, 
'i'he  opacity  is  situated  as  a  shell  between  the  nucleus  and  cortex, 
which  are  l)oth  clear.     It  is  usually  symmetrical. 

{b)  Anterior  polar  {pyramidal)  cataract  is  a  small  dense 
white  centr  il  opacity  on  the  anterior  cajisule  of  the  lens,  usually 
due  to  jjerforation  of  the  cornea  in  early  life,  and  as  a  rule  asso- 
ciated with  corneal  nebula. 

(^)  Posterior  polar  cata^'act  is  situated  at  the  posterior  pole  of 


PLASTIC    UVEITIS.  497 

the  lens.  The  opacity  is  generally  in  radiating  spokes,  and  is 
often  accompanied  by  disease  of  the  vitreous  or  choroid. 

Diagnosis. — When  a  cataract  is  complete  it  looks  white,  amber, 
or  gray,  and  may  be  best  seen  by  dilating  the  pupil,  and  examin- 
ing by  focal  light.  When  incomplete  and  cortical  the  strige  may 
be  seen  by  oblique  illumination  if  the  pupil  is  dilated,  or  by 
throwing  light  into  the  eye  by  the  ophthalmoscopic  mirror  (pre- 
ferably a  plane  mirror),  when  the  striae  will  appear  as  black  lines. 

The  siibjeclive  symptoms  in  incipient  cataract  are  failing  vision, 
black  fixed  spots  or  lines  before  the  eyes,  ability  to  see  better  in 
the  dark  due  to  dilatation  of  the  pupil,  myopia,  and  sometimes 
monocular  diplopia  or  polyopia. 

Treatment. — In  incipient  senile  cataract,  especially  of  the 
nuclear  variety,  weak  atropine  (gr.  ^  to  gr.  j.  to  .^j.)  drops  will 
often  temporarily  improve  the  sight,  and  may  be  ordered  with 
caution. 

The  operations  for  removal  of  the  lens  are  of  two  kinds,  namely 
{a)  extraction,  and  (^)  discission;  extraction  is  always  prefera- 
ble in  hard  cataracts,  and  sometimes  in  soft,  especially  in  adults. 
It  is,  of  course,  necessary  before  proceeding  to  operation  that  the 
condition  of  the  eye  be  satisfactory  as  far  as  the  lids,  conjunctiva 
and  lachrymal  apparatus  are  concerned,  and  that  there  is  good 
perception  and  projection  of  hght.  The  tests  for  the  perception 
and  projection  of  light  should  never  be  omitted,  since,  if  the  eye 
is  blind  or  the  fundus  is  seriously  diseased,  the  removal  of  the 
cataract  would  be  useless  and  unjustifiable.  In  senile  cataract  it 
is  usual  to  wait  till  the  vision  of  one  eye  is  reduced  to  mere  per- 
ception of  light,  and  the  vision  of  the  other  is  insufficient  to  allow 
the  patient  to  follow  his  occupation.  The  general  health  of  the 
patient  must  also  be  investigated,  as  senile  cataract  may  be  asso- 
ciated with  gout,  glycosuria,  and  arterial  disease. 

{a)  The  extraction  operations  are  numerous,  but  the  only  one 
described  here  will  be  the  3  miUimetre  flap  operation,  which  may 
be  performed  with  or  without  iridectomy. 

Operation. — The  first  steps  are  as  in  operation  for  iridectomy 
(see  p.  493).  After  the  introduction  of  the  spring  speculum,  fix 
the  eye  by  seizing  the  conjunctiva  with  fixation-forceps  immedi- 
ately beneath  the  cornea,  pass  the  point  of  a  Graefe's  knife 
through  the  margin  of  the  cornea  at  the  outer  extremity  of  a  hori- 
zontal line  3  millimetres  beneath  the  summit  of  the  cornea  (Fig. 
222),  and  direct  it  carefully  across  the' anterior  chamber  to  the 
inner  corneal  end  of  the  above  horizontal  line ;  complete  the  in- 
cision in  the  corneal  margin  above  by  slow  to  and  fro  upward 
movements  of  the  knife.  An  iridectomy  upwards  is  now  per- 
formed if  required  (see  p.  494).     Fixing  the  eye,  pass  a  cysti- 


498 


DISEASES   OF   REGIONS. 


Fig.  222. 


tome  (Fig.  223)  through  the  wound  and  divide  the  anterior  cap- 
tule  of  the  lens  by  horizontal  incisions.  Draw  the  eye  now 
slightly  downwards,  and  apply  moderate  pressure  by  a  curette 
(Fig.  221)  or  spoon  below  the  lower  edge  of  the  cornea  till  the 
upper  edge  of  the  lens  presents  in  the  wound  (see  Fig.   224) 

and  the  lens  is  gradually  delivered. 
The  speculum  is  now  removed  and 
the  lids  closed  for  a  brief  time,  after 
which  any  soft  matter  is  extracted 
by  pressure  applied  to  the  lower 
surface  of  the  cornea  with  a  curette. 
The  iris  is  now  carefully  replaced 
by  the  curette,  and  both  eyes  band- 
aged up.  The  after-treatment  con- 
sists in  keeping  the  eyes  bandaged 
for  about  a  week,  removing  the 
bandages  and  washing  the  lids 
gently  every  day.  If  there  are  any 
signs  of  iritis,  characterized  by  pain 
and  swelling  of  the  lids,  atropine 
and  leeches  must  be  prescribed  ;  if 
the  corneal  wound  suppurates  it 
should  be  cauterized  or  dusted  with 
iodoform.  The  other  complications  are  prolapse  of  the  iris,  in- 
traocular haemorrhage  and  panophthalmitis.  After  two  months 
the  vision  should  be  tried  for  glasses,  and  if  there  is  much  mem- 
brane left  in  the  pupillary  area,  producing  unsatisfactory  vision,  a 


Showing  speculum  in  eye,  fixation- 
forceps,  and  Graele's  knife  in  posi- 
tion for  performing  flap  section  in 
cataract  extraction.  The  line  ot  flap 
is  also  shown  dotted. 


Fig.  223. 


Cystitomc. 


secondary  operation  must  be  performed.  This  is  done,  the  eye 
being  under  atropine  and  cocaine,  by  passing  a  needle  through  the 
periphery  of  the  cornea  and  breaking  up  the  membrane. 

{b)  'I'he  discission  or  needling  operation,  for  soft  cataract. — 
I'lace  the  patient  in  the  recumbent  position  and  induce  local 
anaesthesia  by  cocaine,  or  if  the  jiatient  be  nervous  or  a  young 
child,  give  chloroform.  'The  pupil  must  be  fully  dilated  before- 
hand by  atropine.  Standing  behind  the  patient's  head  introduce 
the  spring  speculum  (Fig.  219),  and  pass  a  sharp,  straight  stop- 
needle  (Fig.  225)  through  the  periphery  of  the  cornea  into  the 
anterior  chamber.     Push    the    needle    firmly    but   gently   till   it 


PAPILLITIS. 


499 


Fig.  224. 


touches  the  anterior  capsule  of  the  lens  near  its  centre,  and  by  a 
crucial  incision  lacerate  the  capsule  of  the  lens.  Now  slowly 
withdraw  the  needle,  put  atropine  in  the  eye,  and  apply  a  band- 
age. The  effect  of  this  operation,  which  may  have  to  be  repeated, 
is  that  the  lens-matter  passes  into  the  anterior  chamber,  and  is 
softened  by  the  aqueous  and  absorbed.  Occasionally  in  young 
children  repeated  needlings 
may  produce  absorption  of  the 
whole  lens.  As  a  rule,  however, 
after  a  week  or  ten  days  the 
soft  matter  must  be  evacuated, 
especially  if  it  produces  much 
irritation  or  increased  tension. 
This  is  done  by  making  an  in- 
cision in  the  lower  part  of  the 
cornea  by  a  keratome  (Fig. 
220),  as  in  the  first  steps  of  an 
iridectomy  operation  (page 
493).  After  the  corneal  inci- 
sion has  been  made  and  the 
keratome  withdrawn,  a  curette 
(Fig.  221)  should  be  intro- 
duced through  the  corneal 
wound,  and  by  manipulating 
the     curette    the    soft     matter 

passes  out  along  its  groove  and  can  be  removed.  Care  must  be 
taken  on  completion  of  the  operation  that  the  iris  is  not  caught 
in  the  edges  of  the  wound. 

The  CHIEF  INJURIES  of  the  lens 
are  (i)  traumatic  cataract  due  to 
rupture   of  the   capsule,  and  (2)  Stop-needie. 

dislocations    of   the   lens,   usually 
downwards  but  sometimes  into  the  anterior  or  posterior  chambers. 


Showing  the  lens  presenting  in  the  wound 
from  pressure  by  the  spoon  during  the 
operation  of  extraction. 


VI.  Diseases  of  the  optic  nerve,  retina,  and  vitreous. 

The  optic  nerve  fibres  may  be  divided  into  two  sets,  axial  (for 
the  supply  of  the  yellow  spot  region)  ^.nd  periphei-al  (for  the  rest 
of  the  retina). 

Optic  neuritis,  or  inflammation  of  the  optic  nerve,  may  be 
acute  or  chronic,  and  attack  the  whole  or  part  of  the  fibres  of  the 
nerve  ;  and  may  be  divided  into  ( i )  papillitis  affecting  the  intra- 
ocular end  of  the  nerve,  and  ( 2 )  retro-bulbar  neuritris  affecting 
the  nerve  behind  the  globe. 

I.  Papillitis  usually   affects  both   eyes   except  when   due    to 


500  DISEASES   OF   REGIONS. 

orbital  mischief.  The  signs,  chiefly  opthahnoscopic,  are  hyper- 
gemia,  swelUng  and  haziness  of  the  edges  of  the  disk,  distended 
and  tortuous  retinal  veins,  and  small  or  normal  retinal  arteries. 
In  extreme  cases  the  retina  is  much  involved  {papillo-rctinitis^, 
the  distended  veins  being  covered  in  part  by  greyish-white  striae 
or  opacities,  and  the  retina  itself  cedematous  with  flame-shaped 
haemorrhages  often  radiating  from  the  disk.  The  vision  may  be 
normal  or  much  reduced,  and  the  field  for  vision  is  usually 
peripherally  limited.  The  chief  causes  are  cerebral  tumors, 
cerebral  abscess,  tubercular  meningitis,  and  nephritis,  also  orbital 
inflammations,  acute  myelitis,  syphilis,  chlorosis,  and  lead  poison- 
ing. The  treaiinent  is  chiefly  constitutional,  but  in  uni-ocular 
papillitis  incision  into  the  nerve-sheath  has  by  some  been  recom- 
mended. 

2.  Retro-bulbar  neuritis  may  occur  in  one  eye,  due  to 
orbital  periostitis,  etc.,  without  at  first  any  ophthalmoscopic 
signs,  the  only  symptoms  being  loss  of  sight  and  generally  pain 
on  movement  of  the  eye.  There  is  usually  a  central  scotoma. 
As  a  rule  symptoms  of  optic  atrophy  follow. 

Chronic  retro-bulbar  ?ieuriiis  {toxic  amblyopia),  affecting 
usually  both  eyes,  is  an  inflammation  of  the  axial  fibres,  and  is 
found  in  persons  using  excess  of  tobacco  or  alcohol,  and  perhaps 
in  diabetes.  The  symptoms  are  diminution  of  vision,  usually  of 
both  eyes,  the  fields  of  vision  being  normal  as  to  their  periphery, 
but  containing  a  central  scotoma  (blind  spot)  for  red  and  green. 
By  the  ophthalmoscope  there  is  usually  no  change  to  be  seen. 
The  patients  complain  of  mist  before  the  eyes,  and  of  confusing 
gold  and  silver  coins  ;  they  generally  exhibit  want  of  tone,  etc. 
The  treatment  is  directed  to  improve  the  general  health,  and  to 
avoid  the  exciting  cause. 

Atrophy  of  the  optic  nerve  may  be  a  primary  disease,  or 
secondary  to  some  other  optic  nerve  or  retinal  affection.  By  the 
ophthalmoscope  the  optic  disk  is  white  or  greyish,  often  slightly 
cupped  or  filled  up  ;  the  lamina  cribrosa  is  too  plainly  visible  ; 
the  retinal  vessels,  especially  the  arteries,  are  too  small  ;  the 
vessels  may  be  accompanied  by  white  streaks  on  each  side  ;  and 
if  there  has  been  previous  papillitis,  the  vessels  are  curved  antero- 
po&teriorly  and  often  obscured  in  places ;  the  scleral  ring  round 
the  disk  is  too  white,  and  the  edges  of  the  disk  may  be  irregular. 
Atrophy  may  follow  pajjillitis,  retro-bulbar  neuritis,  embolism  of 
the  central  artery  of  the  retina,  retinitis  (especially  ])igmentary), 
and  glaucoma.  A  form  called  progressive  atrophy  is  found  in 
locomotor  ataxia,  insular  sclerosis,  general  paralysis  of  the  insane, 
and  as  a  purely  local  disease  ;  it  is  marked  by  concentric  con- 
traction of  the  fields  of  vision,  loss  of  sight,  color  blindness,  and 


GLIOMA    OF   THE    RETINA.  5  01 

sometimes  central  scotoma,  and  as  its  name  implies,  progresses  to 
complete  blindness.  The  treatment  is  generally  the  administra- 
tion of  anti-syphilitic  remedies,  hypodermic  injections  of  strychnia, 
and  galvanism,  but  the  prognosis  is  as  a  rule  very  bad. 

Retinitis,  or  inflammation  of  the  retina,  is  usually  accompanied 
by  diminution  of  vision,  especially  at  night  or  in  dim  lights,  and 
is  characterized  ophthalmoscopically  by  loss  of  transparency  and 
haze  of  the  fundus ;  soft  white  discrete  or  grouped  spots ;  haemor- 
rhages of  various  sizes  and  shapes  (striated  or  flame-shaped  in 
nerve-fibre  layer,  large  and  serai-circular  in  yellow  spot  region), 
and  by  vitreous  opacities.  Retinitis  is  associated  with  syphilis, 
nephritis,  glycosuria,  leukaemia,  pyaemia  {pttrulent  retinitis)  and 
with  diseases  of  the  circulatory  system  {hcBmorrhagic  retinitis). 
The  treatment  is  chiefly  constitutional,  and  the  eyes  must  be 
shaded  and  used  as  little  as  possible. 

Retinitis  pigjnientosa  is  a  chronic  and  symmetrical  disease, 
occurring  in  early  life,  characterized  by  night  blindness,  and 
great  contraction  of  the  fields  of  vision,  even  though  the  central 
vision  be  normal.  Ophthalmoscopically  the  optic  disk  is  "  waxy- 
looking  "  and  atrophied,  the  retinal  arteries  are  small,  and  there 
is  much  lace-work  retinal  pigment,  especially  near  the  equator. 
The  loss  of  sight  is  progressive,  and  the  disease  often  ends  in 
blindness. 

Embolism  of  the  central  artery  of  the  retina  occurs  usually 
on  the  left  side  and  in  connection  with  heart  disease.  Owing  to 
this  artery  being  a  terminal  one,  complete  plugging  of  it  is  fol- 
lowed by  total  and  sudden  bhndness.  The  ophthalmoscopic  signs 
are  pale  optic  disk,  diffused  retinal  haze,  bright  red  color  at 
yellow  spot,  and  retinal  arteries  near  disk  very  small  and  often 
like  white  threads.  The  treatment  \^  massage  of  the  eyeball,. but 
the  prognosis  is  bad. 

Detachment  of  the  retina  is  due  to  separation  of  the  retina 
from  its  pigment  epithelium  by  haemorrhage  or  serous  exudation. 
It  is  accompanied  by  defect  in  the  field  of  vision  corresponding 
to  the  detachment.  With  the  ophthalmoscope  the  detachment 
looks  greyish,  and  the  retinal  vessels  passing  over  it  are  seen  to 
be  elevated.  The  causes  are  blows  on  the  eye,  myopia,  cicatrices 
following  wounds,  choroidal  tumors,  etc.  lyeatment,  except 
complete  rest,  is  usually  unavailing. 

Glioma  of  the  reiina,  which  has  quite  recently  been  shown 
by  Collins  to  be  an  adenoid  cancer  and  not  a  sarcoma,  occurs  in 
early  Hfe,  and  the  first  symptom  is  a  shining  white  or  yellow  reflex 
seen  behind  the  pupil ;  by  focal  illumination  there  is  found  a 
nodulated  swelling,  with  small  vessels  and  often  haemorrhages  on 
it.     The  tension  may  be  normal  or  increased,  and  there  may  be 


502  DISEASES   OF   REGIONS. 

secondary  glaucomatous  symptoms.  The  Uratiiicnt,  unless  the 
tumor  is  very  large,  is  immediate  excision  of  the  eye  and  removal 
of  as  much  of  the  optic  nerve  as  possible.  The  prognosis  is  very 
unfavorable. 

Vitreous  opacities  are  usually  due  to  inflammation  {Iixalitis) 
associated  with  diseases  of  the  uveal  tract  or  retina,  but  often 
occur  in  extreme  myopia,  and  from  retinal  and  choroidal  haemor- 
rhages. The  opacities  may  be  of  different  shapes  and  sizes,  and 
in  syphilis  are  very  minute  and  dust-like.  The  patient  com- 
plains of  seeing  black  specks  floating  about,  and  vision  is  some- 
times reduced.  Owing  to  degeneration  the  vitreous  may  be 
fluid,  and  contain  cholesterine  crystals. 

SuppuR.-\TiON  OF  THE  vitreous  {suppurative  hyalitis)  is  due  to 
injury  or  to  extension  of  a  purulent  uveitis,  and  is  sometimes 
called  pseudo-glionia,  from  its  yellowish  fundus-reflex.  Foreign 
bodies,  as  steel,  glass,  etc.,  may  be  found  in  the  vitreous,  and, 
when  steel  or  iron,  can  be  removed  by  the  electro-magnet  intro- 
duced through  the  original  wound  when  scleral,  or  through  an 
incision  in  the  sclerotic. 

VII.   Glaucoma. 

Glaucoma  is  a  condition  of  the  eye  dependent  on  excess  of  the 
intra-ocular  pressure.  The  chief  symptoms  are  increased  intra- 
ocular tension  (elicited  by  palpating  the  eyeball  with  both  index 
fingers  through  the  closed  lids)  ;  pain  and  tenderness  ;  enlarge- 
ment of  the  perforating  vessels  ;  impaired  sensibility,  steaminess, 
and  pitted  appearance  of  the  cornea;  shallow  anterior  chamber; 
dilatation  of  the  pupil ;  greenish  fundus  reflex ;  pulsation  of  the 
retinal  arteries,  and  engorgement  of  the  retinal  veins  ;  under- 
mining and  cupping  of  the  optic  disk  ;  diminished  acuity  of  vision 
and  light  sense  ;  and  limitation  of  field  of  vision,  chiefly  at  nasal 
side.  'I'hese  symptoms  are  generally  preceded  or  accompanied 
by  smoky  vision  (everything  seen  in  a  grey  or  yellow  fog),  col- 
ored concentric  rings  (rainbows),  round  lights  (red  outside  and 
bluish -green  inside),  neuralgia  along  the  branches  of  the  fifth 
nerve,  and  rapidly  increasing  presl)yopia,  necessitating  frequent 
changes  of  glasses. 

Varieties. — Glaucoma  may  be  divided  into  (i)  acute,  (2)  sub- 
acute, and  (3)  chronic. 

I.  Acute  glaucoma  is  characterized  by  the  severity  and  sudden- 
ness of  its  onset,  and  from  the  vomiting,  megrim,  etc.,  accompa- 
nying it  has  often  been  mistaken  for  a  bilious  attack.  The  steami- 
ness of  the  cornea  prevents  as  a  rule  any  view  being  obtained  of 
the  fundus,  although  the  jjupil  is  widely  dilated.     The  optic  disk 


GLAUCOMA.  503 

when  visible  is  found  in  first  attacks  not  to  be  cupped,  but  there 
is  marked  pulsation  of  the  retinal  arteries  and  engorgement  of  the 
veins.  Such  an  attack  may  pass  off  after  a  few  days,  but  is  generally 
followed  by  others  until  the  eye  may  pass  into  a  permanent  glau- 
comatous condition  {^absolute  glaucoma)  and  vision  be  totally  de- 
stroyed. Absolute  glaucoma  is  accompanied  by  great  pain  and 
increased  tension,  intra-ocular  haemorrhages,  opacity  of  the  lens, 
ulceration  and  staphyloma  of  the  cornea,  and  shrinking  of  the 
whole  globe.  Some  cases  of  acute  glaucoma  may  be  accompa- 
nied by  severe  intra-ocular  haemorrhage  (Jicemori'hagic  glau- 
coma). 

2.  Subacute  glaucoma  is  characterized  by  the  symptoms  of 
glaucoma  as  given  above.  There  is  generally  a  gradual  progress, 
sometimes  with  exacerbations,  and  it  may  at  any  time  give  rise  to 
acute  glaucoma. 

3.  Chronic  glaucoma  may  follow  on  an  acute  or  subacute 
attack,  but  there  is  an  insidious  and  progressive  form  usually 
attacking  both  eyes,  in  which  all  irritative  signs  are  absent.  With- 
out pain  and  often  with  no  apparent  increase  of  tension,  there  is 
gradual  reduction  of  the  amplitude  of  accommodation,  and  dimin- 
ished corneal  sensibihty,  with  cupping  and  progressive  atrophy  of 
the  optic  disks  often  passing  on  to  absolute  bhndness. 

Pathology. — Glaucoma  is  produced  by  any  circumstance  tend- 
ing to  upset  the  normal  relation  of  the  secretion  and  excretion  of 
the  intra-ocular  fluids.  These  fluids,  secreted  by  the  ciliary  pro- 
cesses, pass  chiefly  out  at  the  angle  between  the  iris  and  the  cor- 
nea {iridic  or  filtration  angle).  This  increased  tension  may  be 
produced  by  hypersecretion  of  the  ciliary  processes,  obstruction 
at  the  filtration  angle,  or  by  serosity  of  the  fluids.  The  most  fre- 
quent cause  is  obstruction  of  the  filtration  angle  due  to  inflamma- 
tory products,  or  to  mechanical  means,  as  growth  of  the  lens,  or 
dilatation  of  the  pupil,  especially  by  atropine.  Glaucoma  occurs 
as  a  rule  in  persons  over  40  years  of  age,  is  frequently  hereditary, 
and  is  often  associated  with  hypermetropia.  It  may  be  secondary 
to  complete  posterior  synechia,  perforating  ulcers  and  wounds  of 
the  cornea,  dislocation  of  the  lens  laterally  and  into  the  anterior 
chamber,  cataract  operations,  intra-ocular  tumors,  and  intra- 
ocular hsemorrhage. 

The  treatment  of  acute  glaucoma  is  by  instillation  of  eserine 
(especially  if  the  attack  is  caused  by  atropine)  or  by  a  large  iri- 
dectomy, as  much  as  one-fifth  of  the  iris  being  removed.  Several 
other  operations  have  been  recommended,  as  sclerotomy,  etc.  In 
glaucoma  absolutum  puncture  of  the  sclerotic  often  relieves  the 
pain.  In  subacute  cases  iridectomy  is  generally  indicated,  but  in 
chronic  glaucoma  without  tension  operative  procedure  probably 
does  little  good. 


504^  DISEASES   OF   REGIONS. 

VIII.  Diseases  of  the  oj'bit. 

SuBCONjL'NCTiVAL  H.tjviORRHAGE,  duc  to  a  blow  on  the  eye  or  to 
rupture  of  a  small  vessel,  owing  to  cough,  etc.,  is  of  a  bright  red 
color.  The  blood  effusion  is  more  marked  anteriorly,  and  does 
not  pass  far  back.  Exactly  the  converse  as  to  the  position  of  the 
blood  applies  to  deep  orbital  hcemorrhage  following  fracture  of  the 
anterior  fossa  of  the  skull,  etc. 

Orbital  abscess  and  orbital  cellulitis,  when  acute,  are  diffi- 
cult to  diagnose  from  each  other.  Though  often  traumatic,  they 
may  be  due  to  cold,  irritation  of  a  tooth,  erysipelas,  pysemia,  etc. 
They  sometimes  originate  in  periostitis.  They  are  usually  char- 
acterized by  swelling  of  the  lids,  cheraosis  of  the  conjunctiva,  pain 
on  movements  of  the  eye  and  on  pressing  back  of  the  eyeball, 
limitation  of  the  ocular  movements,  facial  neuralgia,  and  prop- 
tosis  ;  sometimes  there  is  a  defined,  tender,  fluctuating  swelling. 
If  the  symptoms  are  not  soon  relieved,  especially  in  orbital  cellu- 
litis, papillitis  and  atrophy  of  the  optic  nerve  may  ensue,  and  also 
meningitis.  Orbital  abscess  may  be  chronic  and  simulate  a  solid 
tumor.  The  treatment  consists  in  early  evacuation  of  the  pus, 
hot  fomentations  and  constitutional  remedies. 

Tumors  of  ihe  orbit  usually  cause  protrusion  of  the  eye 
{proptosis),  impairment  of  its  movements,  and  papillitis  or  optic 
atrophy.  Generally  one  orbit  only  is  affected.  The  origin  of  an 
orbital  tumor  may  be  primary,  in  the  lachrymal  gland,  in  the 
loose  orbital  tissues,  in  the  periosteum,  in  the  eyeball,  or  in  the 
optic  nerve  ;  or  secondary,  starting  from  a  neighboring  cavity. 
The  primary  tumors  may  be  cystic  (hydatid,  dermoid)  ;  osseous 
(ivory  exostosis),  sarcomatous,  and  vascular  (ngevi).  Amongst 
the  secondary  tumors  may  be  mentioned  arterio-venous  com- 
munication in  the  cavernous  sinus  giving  rise  to  a  pulsating  tumor, 
and  distension  of  the  frontal  sinus  by  retained  mucus  {frontal 
mucocele').  The  treatment  is  chiefly  the  same  as  in  other  parts. 
Malignant  tumors  should  be  freely  removed  with,  if  necessary,  the 
eyeball  and  the  contents  of  the  orbit,  and  chloride  of  zinc  paste 
in  some  cases  applied  for  a  few  days  afterwards. 

Enucleation  of  the  eye. — Patient  lying  down  and  as  a  rule 
under  general  anaesthesia  ;  operator  standing  behind  the  head  ; 
spring  speculum  in  lids.  Divide  conjunctiva  and  subconjunctival 
tissue  all  round  the  cornea  with  scissors  ;  raise  each  rectus  tendon 
in  succession  on  a  squint  hook  (Fig.  227)  and  divide  each  one 
close  to  the  globe ;  now  separate  the  limbs  of  the  speculum  and 
the  eye-ball  will  project  forwards ;  pass  a  pair  of  stout  curved 
scissors,  closed,  behind  the  globe  from  the  outer  side,  and  feel 
for  the  optic  nerve ;   then  pull  back  the   scissors  slightly,  open 


EMMETROPIA.  *  505 

them,  and  divide  the  nerve.  The  globe,  now  pushed  forwards  by 
the  scissors,  is  taken  between  the  fingers  and  thumb,  and  the 
other  attachments  are  divided  by  the  scissors.  After  the  opera- 
tion, firm  pressure  is  applied  by  a  bandage.  There  is  but  rarely 
any  trouble  from  any  hgemorrhage.  An  artificial  eye  may  be 
given  about  three  months  after  operation,  if  the  socket  is  healthy. 

IX.  Errors  of  refraction  and  acconunodation. 

The  light  percipient  portion  of  the  eye  exists  at  the  external 
layer  of  the  retina  \rods  and  cones),  and  it  is  necessary  for  perfect 
vision  that  images  of  external  objects  should  be  accurately 
focussed  on  this  layer.  Rays  of  light  passing  into  the  eye  are  re- 
fracted at  the  anterior  surfaces  of  the  cornea,  lens  and  vitreous, 
and  brought  to  a  focus  at  a  point  varying  with  the  refraction. 
The  human  eye  for  the  sake  of  simplicity  may  be  represented  by 

Fig.  226. 


Diagram  to  illustrate  errors  of  refraction.  L.  Convex  lens.  X  X.  Principal  axis.  D. 
Divergent  ray.  P.  Parallel  ray.  C.  Convergent  ray.  H,  Em.  and  My.  Position  of 
hypermetropic,  emmetropic,  and  myopic  retinae. 

a  convex  lens  of  23  mm.  focus;  and  the  following  laws  regulating 
the  passage  of  Hght  through  a  convex  lens  will  then  be  applicable 
to  it.  Rays  of  light  passing  through  a  convex  lens  (Fig.  226,  L) 
parallel  (P)  to  the  principal  axis  (X  X),  and  therefore  coming 
from  infinity,  are  brought  to  a  focus  at  a  point  Em.  {^principal 
focus')  varying  inversely  in  distance  to  the  convexity  of  the  lens ; 
rays  coming  from  a  point  (D)  closer  than  infinity  {^divergent  rays) 
are  refracted  further  back  (My.)  from  the  lens  than  the  focal 
point;  and  rays  coming  from  a  point  (C)  beyond  infinity  {^con- 
vergenf)  are  focused  at  H  between  the  lens  and  its  principal  focus 
Em. 

Emmetropia. — In  an  eye    of  normal  refraction  {^emmetropia) 
with  its  accommodation  relaxed,  parallel  rays  (P)  passing  through 


5o6  DISEASES   OF   REGIONS, 

the  pupil  will  be  focussed  by  the  surfaces  at  a  point  (Em.)  rep- 
resented by  the  external  surfaces  of  the  rod  and  cone  layer  of  the 
retina;  divergent  rays  (D)  will  be  focussed  behind  the  retina  at 
My. ;  and  convergent  rays  (C)  in  front  of  the  retina  at  H.  In 
order  to  focus  the  divergent  rays  (D)  upon  the  retina  (Em.),  it 
is  necessary  to  increase  the  convexity  of  the  lens  and  so  shorten 
its  focal  length.  This  is  done  by  accommodation,  and  a  young 
emmetrope  with  normal  accommodation  should  be  able  to  focus 
on  his  retina  all  rays  from  parallel  to  divergent  ones  starting  from 
a  few  inches  from  his  cornea. 

Hypermetropia  is  the  condition  in  v/hich  in  the  eye  at  rest  the 
retina  (H)  only  receives  convergent  rays  (C)  ;  parallel  rays  (P) 
and  divergent  rays  (D)  are  refracted  beyond  the  retina  (H.) 
This  takes  place  from  too  short  a  distance  between  the  cornea 
and  the  retina,  or  from  lessened  convexity  of  the  lens ;  the  usual 
cause  is  congenital  shortness  of  the  axis  of  the  eye.  Hyper- 
metropes  from  this  fact  are  obliged  to  accommodate  for  parallel 
rays,  and  still  more  for  divergent  ones.  The  treati/ieni  naturally 
is  to  increase  the  convexity  of  the  lens  artificially  by  giving  a  con- 
vex lens ;  and  by  so  doing  allowing  parallel  rays  to  be  refracted 
on  the  retina,  and  then  the  ciliary  muscle  will  be  able  to  focus 
divergent  rays  on  the  retina.  In  children  and  young  adults,  to 
find  out  their  hypermetropia  it  is  often  necessary  to  order 
atropine  before  testing  the  refraction.  The  symptoms  of  hyper- 
metropia are  pain  and  discomfort  on  reading,  congested  eyelids 
and  conjunctivae,  spasm  and  fibrillar  twitchings  of  the  lids,  con- 
vergent strabismus,  headache,  etc.  Hypermetropia  is  usually 
congenital,  often  hereditary,  and  is  frequently  associated  with  a 
flat-looking  face,  shallow  orbits  and  small  eyes. 

Myopia  is  the  opposite  condition  to  hypermetropia,  and  in  it 
the  retina  (My)  only  receives  certain  divergent  rays  (D).  It  is 
due  as  a  rule  to  the  axis  of  the  eye  being  too  long,  or  in  some 
cases  to  the  ciliary  muscle  rendering  the  lens  too  convex  {spasm 
of  accommodation).  'I'he  treatment^  except  in  cases  of  spasm  of 
accommodation,  is  to  give  concave  glasses  to  allow  parallel  and 
divergent  rays  to  fall  on  the  retina.  In  low  degrees  of  myopia  it 
is  only  necessary  to  order  glasses  for  distance,  but  in  high  degrees 
it  is  usual  to  order  a  stronger  pair  for  distance,  and  a  weaker  pair 
for  reading,  etc.  In  apparent  myopia  due  to  spasm  of  the  ciliary 
muscle  it  is  necessary  to  order  atropine  to  find  out  the  true  refrac- 
tion. Myopes  often  have  the  head  elongated  in  the  antero- 
posterior diameter,  a  long  face  and  large  prominent  eyes. 
Myopia  is  generally  accompanied  by  a  crescent  at  the  outer  side 
of  the  disk  { posterior  staphy/oma) ,  and  there  may  be  secondary 
choroidal  trouble,  detachments  of  the  retina,  vitreous,  opaci- 
ties, etc. 


STRABISMUS.  507 

Astigmatism  is  the  condition  in  which  one  or  more  of  the  re- 
fractive surfaces  have  not  the  same  curvature  in  all  directions. 
Astigmatism  may  be  divided  into — (i),  irregular,  in  which  there 
is  a  difference  of  refraction  in  the  different  parts  of  the  same 
meridian  due  to  changes  in  the  lens  and  cornea ;  and  (2),  regular, 
where  there  is  a  difference  in  two  meridians  {chief  meridia?is)  at 
right  angles  to  one  another,  and  called  those  of  maximum  and 
minimum  refraction.  It  is  usually  corneal  {sialic  asligtnalisvi) , 
but  may  be  due  to  the  ciliary  muscle  {dynamic  asligmalism). 
Regular  astigmatism  may  be — {a)  simple,  where  one  meridian  is 
emmetropic  and  the  other  hypermetropic  or  myopic,  and  is  then 
called  simple  hypermetropic  or  simple  myopic  astigmatism  ;  {b) 
compound,  where  the  chief  meridians  are  unequally  myopic  (com- 
pound myopic  astigmatism)  or  unequally  hypermetropic  (com- 
pound hypermetropic  astigmatism)  ;  or  {c)  mixed,  where  one 
chief  meridian  is  hypermetropic  and  the  other  myopic.  The 
Ireatment  is  by  cylindrical  glasses  for  simple  astigmatism,  and  by 
cylindrical  glasses  in  combination  with  sphericals  for  compound 
and  mixed. 

Presbyopia. — In  the  eyes. of  all  persons  from  40  to  45  years  of 
age  it  is  found  that,  owing  to  changes  in  the  elasticity  of  the  lens, 
the  ciliary  muscle  begins  perceptibly  to  lose  its  power  of  altering 
the  convexity  of  the  lens.  The  effect  of  this  will  be  to  prevent 
near  objects  being  focussed  on  the  retina;  in  order  to  counteract 
this  condition  and  to  help  the  ciliary  muscle  it  is  necessary  to 
give  convex  glasses  for  reading.  It  has  been  found  that  the  glass 
needed  is  about  one  dioptre  for  every  five  years  after  40.  In 
myopes  wearing  glasses  for  reading,  this  amount  will  have  to  be 
subtracted  from  their  glasses. 

X.  Strabismus  and  ocular  paralysis. 

Strabismus  {squint)  is  always  present  when  the  two  eyes  are 
not  directed  simultaneously  towards  the  same  object,  and  is 
usually  accompanied  at  some  time  by  double  vision  {diplopia). 
Strabismus  occurs  from  over-action,  weakness,  or  paralysis  of  one 
or  more  of  the  extrinsic  ocular  muscles.  It  is  usually  convergent 
or  divergent,  but  may  be  upward  or  downward.  It  may  be  con- 
stant or  occasional  {periodic),  and  though  usually  only  one  eye 
squints,  yet  sometimes  both  eyes  may  do  so  in  turn  {alternating). 
When  the  squinting  eye  follows  its  fellow  normally  in  all  its  move- 
ments, the  squint  is  called  concomitant  in  contra-distinction  to 
paralytic.  Diplopia  is  much  more  marked  in  paralytic  than  in 
concomitant  squint.  The  non-squinting  eye  is  called  the  fixing 
eye,  and  strabismus  may  be  estimated  by  telling  the  patient  to 


5o8  DISEASES   OF   REGIONS. 

look  at  an  object  about  two  feet  away  with  the  fixing  eye,  and 
then  taking  the  distance  between  the  middle  of  the  palpebral 
aperture  and  the  middle  of  the  cornea  of  the  squinting  eye 
{primary  squint)  ;  on  now  making  the  squinting  become  the  fix- 
ing eye,  the  amount  of  deviation  of  the  original  fixing  eye  is  taken 
{secondary  squint).  In  paralytic  cases  the  secondary  squint  ex- 
ceeds the  primary,  but  it  is  equal  to  the  primary  in  concomitant 
squint. 

Convergent  strabismus  {internal  squint)  is  most  commonly  due 
to  hypermetropia,  owing  to  the  fact  that  the  excessive  accommo- 
dation necessitates  a  correspondingly  great  convergence  ;  but  it 
may  occur  occasionally  in  myopia,  and  follows  division  or  paraly- 
sis of  an  external  rectus. 

Divergent  strabismus  {external  squint)  is  caused  from  insuffi- 
ciency of  convergence  power,  and  weakness  of  the  internal  recti, 
especially  in  myopia  ;  from  defective  vision  of  an  eye,  as  in  corneal 
nebulae,  etc.,  and  from  division  or  paralysis  of  an  internal  rectus. 
The  treatment  oi  concomitant  strabismus  is  by  atropine,  eserine, 
spectacles,  prisms,  and  stereoscopic  exercises.  The  operations 
that  may  be  required  are  either  tenotomy  of  the  muscle  of  the 
affected  side,  or  advancement  of  the  muscle  of  the  opposite  side. 
As  a  rule  only  one  eye  should  be  operated  on  at  a  time.  The 
treatment  of  paralytic  strabismus  is  by  constitutional  remedies 
and  galvanism  of  the  affected  muscle. 

Tenotomy  of  the  internal  rectus. — Patient  lying  down  and  under 
cocaine  or  general  ansesthesia  ;  operator  standing  in  front  and  to 
the  right-hand  side.  Introduce  the  spring  speculum,  and  pinch  up 
with  a  pair  of  fixation  forceps  the  conjunctiva  and  subconjunctival 
tissue  at  the  point  of  junction  of  the  lower  horizontal  and  inter- 
vertical  tangents  to  the 
F'G.  227.  cornea.     Divide    this    fold 

with  a  pair  of  blunt-pointed 
scissors,   making    the   inci- 
sion only  large  enough  to 
Strabismus  hook.  admit   the    iK)ints   of    the 

scissors,  and  then,  passing 
the  scissors  through  the  incision,  divide  the  capsule  of  Tenon. 
Pass  the  strabismus  hook  (Fig.  227)  into  the  wound,  directing  its 
point  backwards,  and  then  turn  the  end  of  the  hook  upwards  be- 
tween the  globe  and  the  tendon,  until  its  point  is  seen  beneath 
the  conjunctiva,  at  the  upper  border  of  the  tendon.  Introduce 
the  scissors  through  the  wound  and  open  the  blades  on  either 
side  of  the  tendon  between  the  globe  and  the  hook,  and  by  one 
or  two  snips  cut  through  the  tendon.  Remove  the  hook  and  then 
re-introduce  it  to  see  if  the  tendon  is  completely  divided.     The 


HERPES    OF    THE    LIP.  5O9 

eyes  should  be  bandaged  for  about  twelve  hours.  The  method  is 
the  same  for  the  external  rectus,  but  it  must  be  remembered  that 
the  tendon  is  situated  a  little  further  back. 

Ocular  paralyses. —  Complete  Paralysis  of  the  Thi7-d  Nerve  is 
characterized  by  complete  ptosis ;  external  strabismus ;  inability 
to  move  the  eye  completely  up,  down  or  in ;  crossed  diplopia ; 
moderate  mydriasis  and  inactivity  of  the  pupil  to  all  the  reflexes ; 
and  paralysis  of  accommodation.  Any  one  of  the  muscles  sup- 
phed  by  the  third  nerve  may  be  separately  paralyzed,  also  the 
superior  oblique  (fourth  nerve)  and  the  external  rectus  (sixth 
nerve).  Paralysis  of  the  external  rectus  gives  rise  to  internal 
strabismus,  inability  to  move  the  eye  outwards,  and  homonymous 
diplopia.  It  is  the  most  common  of  the  ocular  palsies,  probably 
from  the  long  course  of  the  sixth  nerve.  All  the  external  ocular 
muscles  may  be  paralyzed  at  the  same  time  {^ophthalmoplegia  ex- 
terna). 

The  intra-ocular  muscles  are  the  pupillary  {sphincter ptipillcB) 
and  the  ciliary.  The  pupillary  muscle  may  be  affected  by  paraly- 
sis of  the  third  or  short  ciliary  nerves,  producing  medium 
mydriasis,  and  by  paralysis  of  the  cervical  sympathetic  or  long 
ciliary  nerves,  producing  partial  miosis.  The  ciliary  muscle  may 
be  paralyzed  {cycloplegia)  by  affections  of  the  third  or  short  cihary 
nerves,  usually  in  conjunction  with  paralysis  of  the  pupillary 
muscle.  It  may  be  paralyzed  alone  as  in  diphtheria.  In  certain 
diseases,  especially  locomotor  ataxia,  the  pupil  acts  to  accommo- 
dation but  not  to  light  {Argyll- Robe7-tson  or  spinal  pupil). 

The  treatment  of  ocular  paralysis  is  chiefly  constitutional. 
Many  are  of  syphilitic  origin  and  require  mercury  or  iodide  of 
potassium,  but  faradization  of  the  affected  muscle  may  also  be  em- 
ployed. In  mydriasis  and  cycloplegia  the  use  of  eserine  is  indi- 
cated. 

NvsTGAMUS  {involuntary  oscillations  of  the  eyeball)  is  generally 
binocular,  and  the  movements  of  the  eyes  are  usually  horizontal 
or  rotatory.  It  occurs  generally  in  early  Hfe,  and  is  then  due  to 
defect  of  sight  from  corneal  ulcer,  etc.,  sometimes  in  adult  life,  in 
patients  with  diseases  of  the  nervous  system,  such  as  disseminated 
sclerosis,  and  in  coal  miners,  in  whom  it  is  probably  due  to  their 
position  at  work. 

DISEASES    OF    THE    LIPS,    CHEEKS,    AND    MOUTH. 

Herpes  of  the  lip. — A  crop  of  herpetic  vesicles  which  burst  in 
a  few  day's  leaving  small  scabs,  are  common  on  the  lip  during 
shght  attacks  of  catarrh,  indigestion,  etc.  Their  occurrence  in 
pneumonia  is  well  known. 


SIO  DISEASES   OF    REGIONS. 

Cracks  and  fissures  of  the  lip  following  exposure  to  cold,  etc., 
in  dyspeptics,  are  very  common,  and  if  neglected,  may  form  deep 
and  painful  fissures,  prone  to  bleed  and  obstinate  to  heal.  A 
simple  ointment,  and  if  persistent  touching  them  with  nitrate  of 
silver,  will  generally  suffice  to  cure  them.  They  must  not  be  mis- 
taken for  the  fissures  about  the  corners  of  the  mouth  so  common 
in  congenital  and  acquired  syphilis. 

Papillomata  or  warty  growths  of  the  lip  are  of  interest  in 
that  they  are  liable  as  age  advances  to  become  epitheliomatous. 
They  may  sometimes  grow  out  in  the  form  of  horns.  Extirpation 
with  the  knife  is  the  proper  treatment. 

Superficial  ulcers  on  the  inner  surface  of  the  lip  are  common 
accompaniments  of  errors  in  digestion,  and  of  secondary  syphilis. 
There  are  usually  similar  ulcers  on  the  side  of  the  tongue  and 
cheeks.  Nitrate  of  silver  or  chromic  acid  lotions  are  the  best 
local  applications. 

N^vus  of  the  lip  when  small  may  be  touched  with  nitric  acid 
or  ethylate  of  sodium ;  and  when  pendulous  and  projecting  from 
the  free  margin,  ligatured.  When  involving  the  whole  substance 
of  the  lip  it  may  be  treated  by  electrolysis,  or  better,  excised  by 
means  of  a  V-shaped  incision. 

Hypertrophy  of  the  up,  generally  the  upper,  is  often  met 
with  in  connection  with  cracks  and  fissures  in  strumous  children, 
and  is  known  as  the  strumous  Up.  A  similar  condition  is  some- 
times met  with  in  congenital  syphilis  and  in  chronic  nasal  catarrh. 
The  thickening,  as  a  rule,  disappears  under  constitutional  treat- 
ment, and  as  the  patient  grows  older.  The  removal  of  a  wedge- 
shaped  piece,  as  advised  by  some,  can  seldom  be  necessary. 

Carbuncle  of  the  lip  is  a  most  dangerous  disease,  as  it  is  very 
likely  to  lead  to  infective  phlebitis  of  the  facial  vein,  which  may 
spread  thence  through  the  ophthalmic  vein  to  the  cavernous  and 
other  cranial  sinuses,  and  terminate  in  infective  meningitis  or  in 
general  blood-poisoning.  Free  incisions  should  be  made,  the 
sloughs  scraped  away,  antiseptics  applied,  and  the  strength  sup- 
ported by  fluid  nourishment  and  stimulants. 

Adenomata,  or  lauial  ca.ANDULAR  tumors  (Paget),  occasionally 
occur  in  the  lip  as  small,  smooth,  elastic  growths  projecting  under 
the  mucous  membrane.  They  sometimes  contain  nodules  of 
cartilage,  and  are  then  of  harder  consistency.  They  should  be 
removed  from  the  mucous  surface  to  avoid  scarring. 

Cysts  due  to  obstruction  of  the  mucous  follicles  are  frequent  in 
the  lip.  They  contain  a  glairy  fluid,  and  appear  as  small,  tense, 
semi-translucent,  globular,  bluish-pink  swellings  on  the  mucous 
surface.  A  free  incision  through  the  mucous  membrane,  and  re- 
moval of  the  cyst-wall  with  forceps,  is  perhaps  the  best  treatment. 


HARE-LIP.  511 

Epithelioma  nearly  always  occurs  in  men,  and  on  the  lower 
lip ;  and  although  it  may  affect  non-smokers,  it  generally  appears 
to  be  due  to  the  irritation  and  heat  of  a  short  clay  pipe.  It  be- 
gins as  a  crack,  small  ulcer,  or  indurated  tubercle,  and  may  either 
spread  superficially  along  the  free  margin  of  the  lip,  or  extend 
deeply  into  its  substance.  Sooner  or  later  it  involves  the  whole 
lip  and  adjoining  parts,  becomes  adherent  to  the  jaw,  and  invades 
the  bone.  The  lymphatic  glands  in  the  neck  become  involved, 
but  dissemination  through  internal  organs  is  rare.  If  removed 
early,  it  may  not  recur  till  after  a  long  period  of  immunity,  or 
perhaps  not  at  all.  It  seldom  returns  in  the  scar,  but  in  the 
lymphatic  glands,  the  patient  dying  of  exhaustion  induced  by 
ulcerating  and  bleeding  masses  in  the  neck.  The  affection  is 
very  apt  to  be  mistaken  for  ha^-d  chancre,  and  the  latter  has  ere 
now  been  cut  away  under  the  impression  that  it  was  an  epithe- 
lioma. The  following  points  should  serve  to  distinguish  them  : — 
I.  Epithelioma  generally  occurs  in  the  old,  and  in  men,  and  on 
the  lower  lip  ;  chancre  in  the  young,  in  women,  and  on  the  upper 
lip.  2.  The  epitheliomatous  ulcer  has  hard,  sinuous,  and  everted 
edges,  and  an  indurated  and  warty  base ;  the  chancrous  is  raised, 
excoriated,  smoother,  and  the  induration  is  more  circumscribed. 
3.  In  the  malignant  affection,  the  glands  are  not  affected  till  late 
in  the  disease — perhaps  six  months  ;  in  the  syphilitic  early,  say 
six  weeks.  Moreover,  in  chancre  secondary  symptoms  will  be 
present  or  soon  appear,  and  the  disease  readily  yields  to  anti- 
syphilitic  remedies.  Treatment. — Free  and  early  excision  is 
imperative.  The  growth  may  be  either  included  in  a  V-shaped 
incision,  the  wound  being  afterwards  united  by  hare-lip  pins,  or  if 
superficial,  freely  shaved  off.  The  glands  in  the  neck,  if  enlarged 
and  not  too  extensively  diseased,  should  be  extirpated  at  the  same 
time.  When  the  bone  is  involved,  a  portion  of  the  jaw  may  be 
removed  if  the  whole  disease  can  be  got  away. 

Hare-lip  is  a  congenital  malformation  in  which  the  upper  lip 
is  vertically  cleft  on  one  or  both  sides  of  the  median  line.  It  is 
so  named  from  its  fancied  resemblance  to  the  lip  of  the  hare.  It 
is  produced  by  the  failure  of  union  of  the  fronto-nasal  process 
which  forms  the  median  portion  of  the  lip  with  the  superior 
maxillary  processes  which  form  the  lateral  portions.  The  fissure 
will,  therefore,  be  opposite  the  suture  between  the  superior  max- 
illary and  premaxillary  bones,  the  situation  at  which  the  union 
between  the  above-mentioned  processes  normally  occurs ;  and  it 
will  be  single  or  double,  according  as  the  failure  of  union  occurs 
on  one  or  both  sides.  It  may  exist  as  a  mere  notch  on  the  free 
margin  of  the  lip,  but  it  more  frequently  extends  deeply  through 
the  substance  of  the  lip  into  the  nostril  above.     Single  hare-lip  is 


512  DISEASES    OF    REGIONS. 

far  more  common  than  double  hare-lip,  and  occurs  much  more 
often  on  the  left  than  on  the  right  side.  The  two  margins  of  the 
cleft  are  often  unequal  in  length,  the  lip  on  one  side  of  the  cleft 
being  on  a  lower  level  than  on  the  other.  In  double  hare-lip  the 
central  portion  is  generally  shorter  than  natural,  and  along  with 
the  premaxillary  bone  and  the  incisor  teeth  frequently  projects 
forwards,  the  two  clefts  being  often  of  unequal  extent.  Cleft 
palate  is  a  frequent  concomitant  of  hare-lip,  and  malformations, 
such  as  club-foot,  spina  bifida,  etc.,  are  not  uncommon  in  other 
parts  of  the  body  at  the  same  time. 

Treat/ncrit. — The  edges  of  the  cleft  should  be  pared,  and  the 
raw  surfaces  brought  into  contact,  and  there  held  by  hare-lip  pins 
or  sutures,  so  that  primary  union  may  occur.  The  operation  is 
best  done  between  the  third  and  fifth  months  of  infancy,  as  very 
young  infants  bear  haemorrhage  badly,  and  laler,  the  troubles  of 
teething  begin.  To  ensure  success  the  child  should  be  brought 
into  the  best  possible  state  of  health  by  careful  nursing  and  feed- 
ing, and  any  constitutional  taint,  as  syphilis,  corrected  by  appro- 
priate remedies. 

There  are  various  methods  of  operating.  Here  only  the  more 
simple  can  be  described.  Whatever  method  is  adopted,  the  ob- 
jects to  be  kept  in  view  are — i,  to  obtain  primary  union  through- 
out the  wound,  and  hence  the  minimum  of  scarring ;  2,  to  ensure 
the  margin  of  the  prolabium  and  free  border  of  the  lip  respect- 
ively being  in  line ;  3,  to  prevent  the  formation  after  the  opera- 
tion of  a  notch  at  the  line  of  union.  These  objects  are  best 
attained  by  well  freeing  the  lip  from  the  gums  at  the  apex  of  the 
cleft  so  as  to  avoid  tension ;  by  using  a  sharp  knife  so  as  to  ensure 
clean  incisions  ;  by  taking  care  to  completely  pare  the  margins  ot 
the  cleft,  and  to  remove  sufficient  tissue  to  secure  broad,  raw  sur- 
faces ;  by  passing  the  hare-lip  pins  on  the  same  level,  and  deeply 
enough  to  bring  the  whole  of  the  raw  surfaces  into  contact ;  and 
by  making  the  cuts  in  paring  the  edges  concave  towards  the 
middle  line  of  the  cleft,  so  as  to  lengthen  the  line  of  union  and 
allow  for  retraction. 

Operation  for  sini:;lc  lia re-lip — Having  placed  a  Smith's  clamp 
(Fig.  228)  on  the  lip  on  either  side 

Fig.  228.  of  the  cleft  to  control  hemorrhage, 

pare  the  edges  of  the  cleft  with  a 
sharp  narrow-bladed  scalpel,  taking 
care  to  remove  the  whole  of  the 
rounded  portion  of  the  prolabium  on 

Smhh's  clamp  for  controllinRha;mor-       ^ach  sidc  of  the  baSC  of  the  clcft  :  and 
rhagt;  during  operation  iorharc-Iip.  ' 

having  freed  the  li])  from  the  gums  at 
the  apex  of  the  cleft,  bring  the  raw  surfaces  together  by  hare-lip 


HARE- LIP.  513 

pins,  passing  the  lower  one  first  to  ensure  the  free  edge  of  the  Hp 
and  prolabium  being  in  Une.  The  lower  pin  should  be  entered  a 
quarter  of  an  inch  from  the  margin  of  the  cleft,  and  made  to 
transfix  the  coronary  artery ;  but  it  should  not  penetrate  the 
mucous  membrane,  as  if  this  be  done  the  mucous  membrane  will 
double  in  and  prevent  union .  A  second  pin  will  generally  be  neces- 
sary, and  should  be  passed  in  the  same  way,  and  a  silk  suture 
twisted  round  each.  The  sharp  ends  of  the  pins  should  be 
nipped  off  with  pliers,  a  small  piece  of  oiled  lint  placed  beneath 
them  to  prevent  injury  to  the  cheek,  and  several  sutures  of 
horse-hair  passed  superficially  to  keep  the  edges  of  the  wound  in 
accurate  apposition.  The  parts  should  then  be  dried,  and  covered 
with  iodoforraized   collodion,  and  a  dumb-bell-shaped  piece  of 

Fig.  22Q.  Fig.  230. 


G:.^ 


Operation  for  single  hare-lip  when  the  fissure  does  not  extend  into  the  nostril. 

Strapping  applied  across  from  cheek  to  cheek  to  prevent  traction. 
The  pins  should  be  removed  at  the  end  of  twenty-four  to  thirty- 
six  hours,  as  otherwise  they  will  leave  scars.  The  twisted  suture 
should  be  left  on  till  firm  union  has  occurred,  and  the  strapping 
re-applied.  Where  the  fissure  does  not  extend  through  the  whole 
lip,  an  inverted  V-shaped  incision  may  be  made,  with  its  angle 
just  above  the  apex  of  the  cleft  (Fig.  229),  each  arm  stopping 
short  of  the  prolabium  ;  the  tissues  included  in  the  arms  of  the 
V  should  now  be  drawn  down,  and  a  diamond-shaped  wound  thus 
formed  (Fig.  230).  On  bringing  the  raw  surfaces  together,  a  pro- 
jection in  place  of  the  fissure  will  exist  on  the  free  border  of  the 
lip  (Fig.  231)  ;  but  this  will  disappear  in  time,  leaving  the  lip 
nearly  natural.  When  there  is  much  irregularity  between  the  two 
portions  of  the  lip  (Fig.  232),  the  incision  on  the  shallower  side 
should  stop  short  of  the  prolabium,  so  as  to  allow  the  flap  thus 
formed  to  remain  attached  at  its  base.  On  the  deeper  side  the 
incision  should  slope  off  at  an  angle  through  the  prolabium,  com- 
pletely removing  the  tissue.  The  flap  left  on  the  shallower  side 
should  be  now  turned  down  and  united  to  the  sloped-oft'  portion 
on  the  deeper  side,  and  the  vertical  portions  of  the  incision 
brought  together  as  usual.     Thus,  what  was  the  free  edge  of  the 


514 


DISEASES   OF   REGIONS. 


cleft  on  the  shallower  side,  now  becomes  the  free  edge  of  the  lip 
(Fig.  233). 

Operation  for  double  hare  Up. — When  the  premaxillary  process 
projects,  it  should  not,  as  a  rule,  be  removed,  but  previous  to  the 
operation  for  uniting  the  lip,  be  partially  detached  with  the  cutting 
pliers,  having  one  blade  blunted  by  being  wrapped  in  lint,  and  then 
be  forced  back  into  place  and  there  secured  by  a  plug  of  gauze  in 
the  wound,  a  pad  over  it,  and  a  dumb-bell-shaped  piece  of 
strapping  fixed  to  the  cheeks.     In  some  cases  the  forcing  into 


Fig.  233. 


Operation  for  single  hare-lip  when  the  sides  of  the  fissure  are  unequal 

place  of  the  premaxilla  will  be  facilitated  by  excising  a  wedge- 
shaped  portion  of  the  nasal  septum  to  which  this  bone  is  attached. 
There  are  many  ways  of  uniting  the  lip.  The  simplest,  perhaps 
(Figs.  234  and  235),  consists  in  paring  completely  the  central 


Fig.  234. 


Fig.  235. 


Operation  for  double  hare- lip. 

portion,  and  then  making  two  flaps  from  the  lateral  portions, 
bringing  them  down  and  uniting  them  to  each  other  below  the 
central  i>ortion,  and  also  to  it,  so  that  they  may  fill  up  the  gap 
left  by  the  deficient  length  of  the  central  portion. 

RoDKNi'  ui.cK.K  most  oftcn  occurs  on  the  face,  especially  near 
the  inner  canthus  of  the  eyelids  and  the  side  of  the  nose,  and  is 
therefore  conveniently  described  here.  It  is  also  met  with  on  the 
scalp,  the  forehead,  and  the  ear,  and  more  rarely  on  the  neck  and 
chin,  and  even  on  the  limbs  and  breast.  Rodent  ulcer  is  generally 
regarded  as  a  form  of  carcinoma ;  it  differs  from  ordinary  carci- 
noma, however,  in  that  it  is  much  slower  in  its  growth,  and  does 


STOMATITIS.  515 

not  become  disseminated,  affect  the  lymphatics,  nor  return  after 
complete  removal.  Pathology. — In  the  early  stages  the  disease  is 
not  an  ulcer  but  a  new  growth,  and  in  exceptional  cases  the  new 
growth  preponderates  over  the  ulceration,  so  that  a  mass  of  some 
size  is  formed.  Rodent  ulcer,  unUke  squamous-celled  epithelioma, 
does  not  grow  from  the  surface,  but  begins  in  the  subcutaneous 
tissue,  and  it  is  only  after  it  has  spread  some  little  distance  super- 
ficially that  the  epidermis  ulcerates.  The  new  growth  is  believed 
to  originate  from  the  external  root-sheath  of  the  hair  follicles,  or 
from  the  sebaceous  or  the  sweat  glands.  Microscopically  the  earli- 
est manifestation  is  the  appearance  under  the  epidermis  of  irreg- 
ular groups  of  small  round  or  oval  cells  lying  in  a  fibrous  matrix. 
These  cells  may  sometimes  be  seen  continuous  with  the  cells  of 
the  external  root-sheath.  Here  and  there  irregular  and  ill-formed 
cell-nests  occur.  The  ulceration  is  preceded,  indeed  is  caused, 
by  the  extension  of  the  new  growth.  From  squamous-celled  epi- 
thelioma rodent  ulcer  differs  in  that  in  the  latter  the  cells  are 
smaller  and  rounder,  cell-nests  are  either  absent  or  are  ill-formed, 
and  the  processes  of  the  growth  spread  superficially  instead  of 
deeply,  and  are  flask-shaped  and  much  branched.  Signs. — The 
disease  is  one  of  advanced  life,  and  seldom  occurs  before  fifty. 
It  is  twice  as  common  in  men  as  in  women.  It  generally  begins 
as  a  small  tubercle,  which  later  becomes  an  ulcer.  The  ulcer  is 
generally  single ;  its  edges  are  irregular,  sinuous,  and  a  little 
raised,  and  but  very  slightly  if  at  all  indurated  ;  its  base  is  shghtly 
depressed,  glazed,  void  of  granulations,  generally  of  a  pale  pink 
color,  and  at  times  covered  with  a  scab.  The  skin  around  is 
healthy.  Although  attempts  at  cicatrization  are  sometimes  seen, 
the  cicatrix  readily  breaks  down,  and  the  ulcer,  which  never  quite 
heals,  slowly  extends,  destroying  muscle,  cartilage,  and  bone,  till 
at  the  end,  perhaps,  of  twenty  or  thirty  years  it  has  destroyed  a 
great  part  of  the  bones  of  the  face,  one  or  both  of  the  eyes,  and 
the  cartilages  and  bones  of  the  nose,  leaving  a  horrible  and  un- 
sightly chasm.  Treatment. — The  growth  or  ulcer  should  be  freely 
excised.  If  done  early  the  prognosis  is  good,  as  it  is  only  when 
some  of  the  growth  is  left  that  a  recurrence  need  be  feared. 
Even  in  the  later  stages  when  much  tissue  has  been  destroyed, 
free  removal  with  the  knife  and  the  application  of  caustics  to  what 
cannot  be  thus  removed,  will  sometimes  stop  the  further  progress 
of  the  growth. 

Stomatitis,  or  inflammation  of  the  mouth,  may  be  divided  into 
the  aphthous,  the  parasitic,  the  ulcerative,  the  syphilitic,  the  mer- 
curial, and  the  gangrenous. 

Aphthous  stomatitis  generally  depends  upon  some  digesdve  dis- 
turbance, and  is  common  in  young  children.     It  is  characterized 


5l6  DISEASES   OF   REGIONS. 

by  white  patches  of  erosion  on  the  mucous  membrane  of  the  Hps, 
cheek  and  tongue.  Rhubarb  and  magnesia,  and  locally  borax 
and  honey,  are  the  usual  remedies. 

Parasitic  stomatitis,  or  thrush,  resembles  the  preceding,  but 
depends  upon  the  presence  of  a  parasite  known  as  the  oidiiim 
albicaiis.  It  is  generally  merely  symptomatic  of  other  diseases, 
to  the  alleviation  and  cure  of  which  the  treatment  should  be 
directed. 

Ulcerative  stomatitis  is  more  serious,  but  is  still,  as  a  rule, 
superficial.  It  may  depend  upon  digestive  disturbance,  local  irri- 
tation of  cutting  teeth,  or  bad  hygiene.  The  ulcers  are  covered 
with  a  gray  slough,  the  gums  are  red  and  swollen,  and  the  breath 
is  foul.  A  stimulating  plan  of  treatment  is  generally  required, 
with  attention  to  the  digestive  functions,  hygienic  surroundings, 
etc.  Locally,  the  mouth  should  be  rinsed  out  with  a  wash  of 
chlorate  of  potash. 

Syphilitic  stomatitis  is  common  during  the  secondary  and  ter- 
tiary stages  of  syphilis,  and  requires  no  further  mention. 

Mercurial  stomatitis,  depending  upon  an  overdose  of  mercury, 
or  some  idiosyncrasy  of  the  patient  to  the  drug,  is  of  less  frequent 
occurrence  in  its  severe  forms  than  formerly.  It  is  attended  with 
foul  breath,  swollen  tongue,  spongy  gums,  profuse  salivation,  swell- 
ing of  the  parotid  and  submaxillary  glands,  and  loosening  of  the 
teeth.  It  may  terminate  in  gangrenous  ulceration,  with  exten- 
sive destruction  of  the  soft  tissues,  and  perhaps  necrosis  of  the 
bones.  Chlorate  of  potash,  both  internally  and  as  a  mouth-wash, 
should  be  given  ;  and  the  strength  supported  by  fluid  nourish- 
ment and,  if  indicated,  by  stimulants. 

Gans;rcjioi(s  stomatitis  or  cancrum  oris,  is  a  phagedtenic  ulcer- 
ation, which  begins  on  the  inside  of  the  cheek,  and  if  not  checked 
rapidly  involves  its  whole  thickness.  It  is  very  apt  to  terminate 
in  blood-poisoning.  It  appears  to  depend  upon  thrombosis  of 
the  capillaries,  a  condition  recently  shown  to  be  induced  by  the 
presence  of  a  specific  micro-organism.  It  is  most  frequently  met 
with  in  under-fed,  debilitated  children  recovering  from  one  of  the 
exanthemata,  typhoid  fever,  etc.,  or  subjected  to  bad  hygienic 
conditions.  A  foul  and  black  slough  forms  in  the  mouth,  and  a 
dusky  patch  soon  appears  on  the  surface  of  the  cheek,  which  be- 
comes hard  and  brawny,  and  then  black.  If  the  disease  is  not 
soon  arrested,  extensive  sloughing  occurs,  typhoid  symptoms  set 
in,  and  the  patient  dies  comatose,  of  general  blood-]K)isoning,  or 
of  bronchitis  or  pneumonia.  It  appears  to  be  of  a  nature  similar 
to  the  gangrenous  inflammation  of  the  female  genitals  known  as 
noma.  The  treatment  must  be  energetic.  'J'he  parts  should  be 
well  dried,  and  thoroughly  destroyed  with  fuming  nitric  acid ;  or 


BURSAL   AND   DERMOID    CYSTS.  517 

boroglyceride  may  be  applied  in  milder  cases.  The  strength  must 
be  supported  with  strong  beef-tea,  brandy-and-egg  mixture  and 
nutrient  enemata.  Recumbency  should  be  insisted  upon  during 
convalescence,  since  there  is  a  tendency  to  fatal  syncope,  which 
may  remain  for  some  time. 

Salivary  calculi  are  sometimes  met  with  blocking  the  orifice 
of  Wharton's  duct,  or,  more  rarely,  one  of  the  ducts  of  the  other 
salivary  glands.  They  are  composed  of  animal  matter,  impreg- 
nated with  phosphate  and  a  trace  of  carbonate  of  lime.  Gen- 
erally they  can  be  seen,  or  at  any  rate  felt,  in  the  interior  of  the 
mouth,  as  hard  bodies  in  the  course  of  the  duct.  They  may  give 
rise,  by  causing  retention  of  the  secretion  of  the  gland,  to  swell- 
ing, pain,  and  tenderness  in  the  obstructed  gland,  and  sometimes 
to  suppuration  and  salivary  fistula.  An  incision  through  the 
mucous  micmbrane  over  the  calculus  will  allow  of  its  removal 
with  a  scoop  or  forceps.  Should  stricture  of  the  duct  follow  it 
must  be  divided  transversely. 

Ranula  is  a  bluish-white,  semi-translucent,  globular  or  ovoid 
swelling  situated  in  the  floor  of  the  mouth  beneath  the  tongue, 
and  containing  a  glairy  mucoid  fluid.  It  is  probably  produced 
by  the  enlargement  of  one  of  the  mucous  follicles  so  numerous  in 
that  situation.  Mr.  Morrant  Baker  has  conclusively  shown,  by 
introducing  a  small  bristle  into  the  duct  by  the  side  of  the  swell- 
ing, that  it  is  not  usually  a  dilatation  of  Wharton's  duct,  as  was 
formerly  taught.  It  is  painless,  but  interferes,  to  a  greater  or 
less  extent  according  to  its  size,  with  the  movements  of  the 
tongue  in  speech  and  deglutition.  Sometimes  these  cysts  attain 
a  large  size  and  extend  deeply  in  the  neck,  presenting  below  the 
jaw.  Treatment. — After  painting  the  parts  with  a  twenty  per 
cent,  solution  of  cocaine,  a  portion  of  the  cyst-wall  should  be 
pinched  up  with  nibbed  forceps,  and  a  good-sized  piece  of  it  ex- 
cised with  curved  scissors.  A  deep  hold  must  be  taken,  or  the 
mucous  membrane,  which  adheres  but  loosely  to  the  cyst,  will 
alone  be  caught  up.  The  fluid  should  be  squeezed  out,  and  the 
lining  membrane  cauterized  with  a  stick  of  nitrate  of  silver,  and 
the  opening  kept  free  by  the  daily  passage  of  a  probe,  so  that 
healing  may  take  place  from  the  bottom.  If  a  mere  incision  is 
made,  the  cyst  is  nearly  sure  to  fill  again.  A  seton  will  sometimes 
answer,  but  it  is  not  always  reliable  ;  if,  therefore,  the  treatment 
above  indicated  fails,  the  cyst  should  be  dissected  out. 

Bursal  and  dermoid  cysts. — Pathology. — These  cysts,  which 
contain  a  glairy  fluid  or  a  grumous  sebaceous  material,  project 
both  under  the  tongue  and  in  the  neck  below  the  jaw.  Those  in 
the  middle  line  of  the  neck  or  tongue  may  be  due  to,  i.  En- 
largement of  the  hyoid  bursa,   2.  Dermoid  formations,  and   3. 


5t8  diseases  of  regions. 

Remains  of  the  thyroid  duct  {J^is's  duct).  In  the  last  case  they 
are  situated  («)  near  the  foramen  caecum,  bulging  under  the 
tongue,  or  {b)  in  the  neck,  projecting  perhaps  as  low  as  the 
pyramidal  or  middle  lobe  of  the  thyroid  body.  Those  on  one 
side  of  the  neck  are  dermoid  formations  in  the  regions  of  the 
branchial  clefts.  As  they  increase  in  size,  they  send  prolonga- 
tions in  various  directions,  and  sometimes  become  connected 
with  the  carotid  sheath.  Signs. — The  middle-line  cysts  form 
fluctuating  swellings  in  the  front  of  the  neck,  and  when  due  to 
enlargement  of  the  hyoid  bursa  are  often  translucent.  In  the 
lateral  cysts  fluctuation  may  sometimes  be  obtained  by  one  finger 
in  the  mouth  and  another  on  the  cyst  in  the  neck.  When  they 
extend  to  the  sheath  of  the  great  vessels  the  pulsation  of  the 
carotid  may  be  communicated  to  them.  Treatment. — The  bursal 
cysts  should  be  removed  through  a  vertical  incision  over  them  in 
the  middle  line  of  the  neck.  The  dermoids,  when  they  project 
under  the  tongue  and  are  not  too  large  and  apparently  movable, 
may  at  times  be  shelled  out  through  an  incision  in  the  floor  of  the 
mouth  to  prevent  scarring.  Otherwise  they  must  be  dissected 
out  through  an  incision  in  the  neck. 

diseases  of  the  tongue. 

Tongue-tie  is  due  to  the  tongue  being  more  or  less  tightly 
bound  down  to  the  floor  of  the  mouth  by  the  shortness  of  the 
fraenura.  It  is  apt,  when  well  marked,  to  interfere  with  sucking, 
and  later,  with  distinct  speech.  It  is  easily  remedied  by  divid- 
ing the  fraenum  with  probe-pointed  scissors,  care  being  taken  to 
direct  the  points  downwards  and  backwards  and  merely  to  notch 
the  free  border,  lest  the  ranine  artery  be  wounded,  an  accident 
which,  in  infants,  has  been  attended  with  severe,  and  in  some 
cases  fatal,  haemorrhage.  If  the  division  of  the  fraenum  is  too 
free,  the  tongue  may  loll  backwards,  pressing  the  epiglottis  over 
the  entrance  of  the  larynx,  and  produce  severe  dyspnoea  or  even 
fatal  asphyxia — "  swallowing  the  tongue,"  as  it  has  been  called. 
On  drawing  the  tongue  forwards  the  symptoms  will  at  once  cease  ; 
but  a  ligature  should  be  passed  through  its  tip  and  secured  to  the 
cheek,  with  instructions  to  again  draw  the  tongue  forwards  with 
the  ligature,  should  the  symptoms  recur. 

NoN-DiFFEREN'iiATioN  of  the  tonguc  from  the  surrounding 
tissues  gives  rise  to  the  rare  malformation  in  which  the  tongue 
appears  bound  down  to  the  floor  of  the  mouth.  This  condition 
must  not  be  mistaken  for  that  called  ankyloi^/ossia,  in  which  the 
tongue,  in  consequence  of  cicatricial  adhesions,  presents  a  similar 
appearance.  Division  of  the  adhesions  in  the  latter  case  will  do 
much  to  remedy  the  affection. 


CHRONIC   SUPERFICIAL   GLOSSITIS.  519 

Macroglossia,  or  hypertrophy  of  the  tongue  may  be  congenital 
or  acquired.  In  either  case  it  is  rare.  Signs. — The  whole  tongue 
is  uniformly  enlarged,  and  sometimes  so  much  so  that  it  presses 
forwards  the  alveolar  process  of  the  lower  jaw  with  the  incisor 
teeth,  and  protrudes  from  the  mouth,  hanging  downwards  as  low 
as  the  chin.  When  thus  exposed  the  mucous  membrane  becomes 
cracked,  spongy,  and  bluish- red,  and  is  subject  to  repeated  attacks 
of  subacute  glossitis.  Pathology. — The  affection  appears  to  be 
due  to  a  blocking  of  the  lymphatics  at  the  base  of  the  tongue ;  at 
any  rate  the  lymphatics  are  found  enlarged  and  distended  with 
lymph,  and  the  connective  tissue  is  increased  in  amount  and  in- 
filtrated with  lymphoid  corpuscles.  It  appears  related,  therefore, 
with  elephantiasis — a  condition  sometimes  found  co-existing  in 
the  neck  and  other  parts  of  the  body.  The  only  treairnent  of 
much  avail  is  excision  of  part  of  the  organ.  The  removal  of  a 
V-shaped  piece  has  been  attended  with  excellent  results.  It 
should  be  done  before  the  teeth  and  jaw  have  been  deformed  by 
the  pressure. 

Acute  parenchymatous  glossitis,  or  deep  inflammation  of  the 
tongue,  may  be  due  to  mercury,  fever,  iodism,  injury,  carious 
teeth,  stings  of  insects,  abscesses  beneath  the  jaw ;  sometimes 
there  is  no  apparent  cause.  Signs. — In  severe  cases  the  whole 
tongue  is  swollen,  and  protrudes  from  the  mouth,  interfering  with 
speech  and  deglutition,  and  sometimes  threatening  suffocation. 
It  frequently  ends  in  abscess.  It  is  often  attended  with  high 
fever  and  salivation,  and  may  be  quite  sudden  in  its  onset.  Treat- 
ment.— Should  a  brisk  purge  and  the  milder  measures  applicable 
to  acute  inflammations  fail,  free  longitudinal  incisions,  which 
need  not  be  deep,  should  be  made  along  the  dorsum  of  the 
tongue,  and  the  svveUing  will  usually  subside  in  a  few  hours. 

Suppuration  and  abscess  sometimes  follow  an  attack  of  acute 
glossitis  ;  but  the  preceding  inflammation  may  be  so  slight  as  to 
be  overlooked.  The  abscess,  which  then  forms  a  firm,  tense, 
elastic  swelling  in  the  substance  of  the  tongue,  may  be  mistaken 
for  a  gumma  or  carcinoma ;  but  the  diagnosis  is  readily  made  by 
an  exploratory  puncture.  A  free  incision  is  the  proper  treatment, 
the  cavity  filling  up  in  a  few  days. 

Chronic  superficial  glossitis,  also  known  as  psoriasis,  ichthy- 
osis, or  leucoplakia  of  the  tongue,  is  a  chronic  inflammation  of 
the  mucous  membrane,  and  may  be  induced  by  syphilis,  excessive 
smoking,  some  forms  of  dyspepsia,  the  abuse  of  spirits,  jagged 
teeth,  etc.  It  begins  as  a  hypersemia  of  the  papillary  layer,  and 
presents  at  this  stage  slightly-raised  red  patches  better  seen  if  the 
tongue  be  dried.  This  is  followed  by  excessive  growth  of  epithe- 
lium, the  cells  of  which  assume  a  horny  character,  and  the  patches, 


520  DISEASES   OF   REGIONS. 

which  were  previously  red,  become  bluish  white,  and  later,  opaque 
white.  Several  of  the  patches  may  now  coalesce,  covering  in 
severe  cases  the  whole  or  greater  part  of  the  dorsum  of  the  tongue. 
It  is  this  condition  to  which  the  term  psoriasis  has  been  applied, 
from  its  superficial  resemblance  to  psoriasis  of  the  skin.  Still 
later,  from  excessive  heaping  up  of  the  epithelium,  the  surface  of 
the  organ  becomes  cracked  and  nodular,  stimulating  ichthyosis,  a 
name  by  which  it  has  also  been  called.  As  the  pathology  of  the 
affection,  however,  is  distinct  from  that  of  the  above-named  affec- 
tions of  the  skin,  it  would  be  better  to  drop  these  terms,  and  to 
call  the  affection  either  leucoplakia  {white  patches)  or  chronic 
glossitis.  After  variable  periods,  the  hypertrophied  papillae  may 
atrophy,  or  ulceration  may  occur  ;  or  the  epithelium  may  grow 
into  the  substance  of  the  tongue  and  the  disease  become  epithe- 
liomatous.  At  times  the  inflammation  does  not  give  rise  to  an 
increase  of  epithelium,  the  tongue  then  appearing  smooth,  glazed 
and  red.  The  disease,  except  when  ulceration  occurs,  causes 
little  or  no  pain,  and  often  gives  rise  to  no  inconvenience  ;  but  it 
should  always  be  carefully  watched  for  any  sign  of  its  becoming 
epitheliomatous.  A  similar  condition  of  the  mucous  surface  of 
the  lips  and  cheeks  is  a  common  accompaniment,  especially  in 
smokers  {smoker'' s  patches).  Treatment. — All  sources  of  irrita- 
tion, especially  smoking,  stimulants  and  condiments,  should  be 
avoided ;  anti-syphilitic  remedies  given  where  indicated ;  and 
soothing  washes  of  chlorate  of  potash  or  borax  applied.  Should 
any  of  the  leucoplakial  patches  show  signs  of  ulceration,  the  whole 
patch  should  be  at  once' excised  ;  or  should  signs  of  epithelioma 
already  be  present,  the  whole  or  half  of  the  tongue  should  be  re- 
moved. 

Ulceration  of  the  tongue  may  be  simple,  tubercular,  syphi- 
litic, lupoid,  or  epitheliomatous.  Aphthous  ulceration,  and  that 
following  mercurial  salivation,  have  been  described  under  stoma- 
titis. 

Simple  ulceration  may  depend  on  digestive  disturbance  {dys- 
peptic ulcer)  or  on  irritation,  as  of  a  sharp  or  carious  tooth,  hot 
pipe  stem,  etc.  {dental  or  irritable  ulcer).  Both  varieties  are 
generally  superficial,  and  unattended  with  the  induration  and  in- 
filtration characteristic  of  epithelioma.  The  dyspeptic  ulcer  usu- 
ally occurs  on  the  dorsum  of  the  tongue  near  the  tip.  The 
ulceration  is  sometimes  extensive  and  multiple,  and  is  often 
accompanied  by  some  superficial  glossitis  at  other  parts  of  the 
tongue.  The  dental  ulcer  is  situated  on  the  side  of  the  tongue, 
and  generally  corresponds  with  a  carious  or  sharp  tooth.  At  first 
it  may  be  a  mere  superficial  red  abrasion,  but  if  neglected,  it  be- 
comes a  distinct  ulcer,  irregular  in  shape,  and  surrounded  with  an 


ULCERATION  OF  THE  TONGUE.  52 1 

inflammatory  area.  The  edges  are  abrupt  and  a  little  raised,  but 
not  everted  ;  the  base  is  depressed,  sloughing,  and  sometimes 
phagedaenic,  but  not  indurated  unless  the  ulcer  has  existed  some 
time,  when  it  may  become  callous.  It  is  always  unattended  with 
infiltration.  Treatment. — In  the  dyspeptic  ulcer  the  diet  and 
bowels  must  be  carefully  regulated,  bismuth  or  soda  in  infusion  of 
calumba,  given  internally,  and  soothing  washes  or  borax  and 
honey  applied  locally.  Caustics  must  be  avoided.  In  the  dental 
ulcer  any  offending  tooth  must  be  filed,  stopped,  scraped,  or  ex- 
tracted, in  short,  every  source  of  irritation  removed.  The  ulcer 
will  then  rapidly  heal,  but  if  neglected  it  may  become  epithelio- 
matous.  On  the  first  appearance  of  infiltration,  therefore,  free 
excision  is  imperative. 

Tubercular  ulceration  of  the  tongue  is  rare,  and  generally 
occurs  in  young  adult  males,  the  subjects  of  phthisis  or  of  general 
tuberculosis.  It  usually  begins  as  a  small  pimple  or  nodule  on 
the  dorsum  of  the  tongue,  especially  near  the  tip.  This,  after  a 
short  time,  breaks  do.vvn  into  round,  oval  or  irregular,  painful 
ulcer.  The  edges  are  slightly  raised,  vertical,  inverted,  or  under- 
mined, sometimes  slightly  thickened,  but  never  everted  or  greatly 
indurated.  The  base  is  uneven  or  nodular,  and  covered  with  coarse, 
pinkish-grey  granulations,  or  with  a  grey  or  yellow  shreddy  slough. 
Sometimes  several  smaller  ulcers  appear  around  the  one  first 
formed,  and  coalesce  with  it.  The  ulceration  usually  progresses 
in  spite  of  treatment,  the  patient  dying  of  phthisis  or  other  tuber- 
cular affection.  The  absence  of  glandular  enlargement,  of  indu- 
ration, and  of  signs  of  syphilis,  along  with  the  presence  of  tubercle 
elsewhere,  and  the  characters  given  above,  should  serve  to  distin- 
guish it  from  syphilitic  and  epitheliomatous  ulceration.  Treat- 
ment has  hitherto  been  of  httle  service.  The  ulcer,  however,  may 
be  soothed  by  Ferrier's  snuff  or  cocaine ;  or  if  the  constitutional 
state  does  not  forbid,  it  may  be  scraped  with  a  Volkmann's  spoon, 
and  dusted  with  iodoform,  cauterized  with  nitrate  of  silver,  or  cut 
out.  The  usual  constitutional  treatment  for  tubercle  should,  of 
course,  at  the  same  time  be  employed. 

Syphilitic  ulceration  may  be  divided  for  practical  purposes  into 
the  superficial  and  deep  ;  the  former  commonly  occurring  in  the 
early,  the  latter  in  the  later  stages  of  syphilis,  {a)  The  superfi- 
cial ulcers  direct  the  side  of  the  tongue,  and  are  frequently  associ- 
ated with  similar  ulcers  on  the  lips,  cheeks,  palate,  gums  and 
fauces.  They  are  usually  of  an  oval  or  irregular  shape,  and  have 
sharply  cut  edges,  an  ash-grey  base,  and  a  surrounding  areola  of 
inflammation.  They  readily  disappear  under  the  influence  of 
mercury,  and  the  local  application  of  a  lotion  of  nitrate  of  silver 
or  chromic  acid.  These  ulcers  are  sometimes  associated  with  a 
22* 


522  DISEASES   OF   REGIONS. 

heaping-up  of  epithelium  similar  to  that  which  occurs  in  mucous 
tubercles,  (d)  The  deep  ulcers  are  due  to  the  breaking  down  of 
syphilitic  gummata.  They  generally  occur  in  the  centre  of  the 
dorsum  of  the  tongue  as  deeply  irregular  excavations,  with  raised, 
slightly  concave  or  undermined  edges,  and  a  base  covered  vv^ith  a 
yellow,  slough  and  di-bris  of  breaking-down  tissue.  They  are  usu- 
ally surrounded  with  a  red  areola.  On  healing,  they  have  char- 
acteristic, cracked  or  stellate-looking  scars.  Their  situation  at  or 
near  the  middle  of  the  tongue,  the  absence  of  induration  and  of 
glandular  enlargement,  the  history  of  the  previous  gummatous 
swellings  and  of  syphilis,  and  their  amenability  to  anti-syphilitic 
remedies,  should  serve  to  distinguish  them  from  squamous  or 
other  forms  of  carcinoma.  Treatment. — Large  doses  of  iodide  of 
potassium,  combined  with  quinine,  if  the  constitution  is  at  all 
broken,  and  the  local  application  of  a  cleansing  gargle,  as 
chlorate  of  potash,  will  rapidly  cause  them  to  heal.  The  scars 
left  by  these  ulcers  sometimes,  though  rarely,  degenerate  into 
epithelioma.  Should  any  induration  therefore  appear  in  them, 
their  free  removal  with  the  knife  should  at  once  be  undertaken. 

Lupoid  ulceration  of  the  tongue  is  very  rare.  I  have  only  seen 
one  case  during  an  expeiience  of  twenty  years  at  St.  Bartholo- 
mew's Hospital.  This  was  under  the  care  of  my  colleague,  Mr. 
Butlin.  The  case  occurred  in  a  young  girl  with  extensive  lupus 
about  the  nose,  lips,  and  mouth.  Scraping  with  a  Volkmann's 
spoon  was  the  treatment  adopted. 

Epithelioviatous  ulceration  is  due  to  the  breaking  down  of 
squamous  carcinoma.  It  is  described  under  ulceration  instead  of 
amongst  new  growths,  as  in  consequence  of  the  irritation  from 
the  teeth,  and  the  movements  of  the  tongue,  epithelioma  in  this 
situation  very  rapidly  ulcerates,  even  if  it  does  not  begin  as  an 
ulcer ;  hence  it  is  from  other  ulcers  rather  than  from  new  growths 
that  it  has  to  be  distinguished.  It  is  much  more  common  in 
men  than  in  women,  and  seldom  occurs  under  the  age  of  forty. 
Often  it  is  due  to  the  irritation  of  a  carious  or  sharp  tooth,  and 
then  begins  as  a  dental  ulcer ;  or  it  may  arise  in  the  scar  left  by  a 
syphilitic  ulcer,  or  follow  upon  the  condition  of  the  tongue  known 
as  chronic  superficial  glossitis.  Occasionally  it  begins  as  a  wart 
or  pimple  in  i)atients  in  whom  no  cause  for  it  can  be  assigned.  It 
is  most  common  on  the  side  of  the  tongue  opposite  the  molar  or 
bicuspid  teeth.  The  ulcer  is  irregular,  with  raised,  sinuous,  hard 
and  everted  edges,  and  uneven,  excavated,  or  warty  base  ;  while 
the  tissues  around  are  infiltrated  and  indurated.  Its  growth  is 
generally  rapid,  and  attended  with  neuralgic  pain  and  copious 
salivation.  If  allowed  to  take  its  course  it  spreads  backwards  to 
the  pillars  of  the  fauces,  downwards  to  the  floor  of  the  mouth,  and 


TUMORS  OF  THE  TONGUE.  523 

inwards  to  the  opposite  half  of  the  tongue  ;  while  the  submaxillary 
lymphatic  glands,  and  later  the  lymphatic  glands  in  the  neck,  be- 
come enlarged,  and  the  parts  about  the  angle  of  the  jaw  infiltrated 
and  matted  together  by  the  disease.  Secondary  ulcers  then  form 
from  the  breaking  down  of  the  glands  in  the  neck,  and  the  patient 
dies,  worn  out  by  pain  and  irritation,  or  exhausted  by  haemor- 
rhage ;  but  hke  squamous  carcinoma  in  other  parts,  it  seldom  be- 
comes disseminated  in  distant  organs.  Treatment. — Early  and 
free  extirpation  ought  in  every  instance  to  be  undertaken,  but 
even  then  a  recurrence  in  the  glands  of  the  neck  is  only  too  fre- 
quent. When  the  disease  has  attained  some  magnitude,  the  pro 
priety  of  removal  becomes  a  question,  and  opinions  differ  under 
what  circumstances  it  ought  to  be  attempted.  Its  removal  is  con- 
traindicated  : — i,  when  it  has  extended  so  far  backwards  that  the 
finger  cannot  reach  healthy  tissue  beyond  it ;  2,  when  it  is  iirmly 
and  extensively  adherent  to  the  jaw ;  3,  when  the  tongue  is  firmly 
bound  down  to  the  floor  of  the  mouth ;  4,  when  the  glands  not 
only  below  the  jaw,  but  deep  in  the  neck,  are  much  implicated ; 
and  5,  when  the  patient  is  too  weak  or  emaciated  from  the  dis- 
ease itself,  or  from  disease  of  other  organs,  to  stand  an  operation. 
Moderate  enlargement  of  the  glands,  slight  adhesion  to  the  jaw, 
and  some  infiltration  of  the  floor  of  the  mouth,  do  not,  in  my 
opinion,  forbid  an  operation  (especially  if  the  patient  is  suffering 
from  much  pain,  and  is  otherwise  in  good  health),  provided  the 
whole  of  the  disease  with  the  enlarged  glands  can  be  got  away. 
Where  the  disease  is  regarded  as  beyond  the  reach  of  extirpation, 
the  pain  and  salivation  may  often  be  relieved  by  removing,  not  only 
decayed,  but  sound  teeth  that  may  be  irritating  the  growth,  or  by 
stretching  or  dividing  the  gustatory  nerve.  This,  which  however 
is  sometimes  impracticable  on  account  of  the  extension  of  the 
growth,  may  be  done  by  making  a  small  incision  transversely  from 
the  last  molar  tooth  through  the  mucous  membrane  to  the  side  of 
the  tongue,  then  passing  an  aneurysm  needle  into  the  wound,  and 
hooking  up  the  nerve,  which  is  here  quite  superficial.  Cocaine, 
or  morphia  and  glycerine,  may  be  painted  on  the  part,  whilst  the 
patient's  remaining  span  of  Ufa  may  be  rendered  bearable  by  in- 
creasing doses  of  opium  or  morphia. 

Tumors  of  the  tongue. — Papillomatous  »r  warty  growths  are 
not  uncommon,  and  may  be  distinguished  from  epithelioma,  into 
which  they  are  liable  to  degenerate  as  age  advances,  by  the  ab- 
sence of  induration  about  their  base.  They  should  be  freely  re- 
moved by  the  knife  or  scissors.  Vascular  tumors  or  ncevi  and 
lymphangiomata  are  occasionally  met  with,  and  may  be  destroyed 
by  the  ligature  or  knife.  Fibrous,  fatty,  myxomatous,  adenomatous, 
sarcomatous  and  carcinomatous  tumors  other  than  the  squamous 


524 


DISEASES   OF   REGIONS. 


variety,  which  has  already  been  described  under  epitheliomatous 
ulceration,  are  too  rare  in  the  tongue  to  call  for  further  remark. 
For  mucous  tubercles  and  gummata  see  Syphilis  of  the  Tongue. 

Syphilis  of  the  Tongue  may  occur  as:  i.  Primary  chancre. 
2.  Mucous  tubercles.  3.  Superficial  glossitis.  4.  Superficial  and 
deep  ulceration,  and  5.  Gummata.  Primary  chancres,  which  are 
very  rare  in  this  situation,  require  no  description.  Mucous 
tubercles  consist,  as  elsewhere,  of  heapings  up  of  epithelium  over 
infiltrated  and  enlarged  papillse,  and  appear  as  flattened  elevations 
of  a  grayish-white  color.  They  are  generally  present  on  the 
palate  and  fauces  at  the  same  time.  Mercury  internally,  and 
black-wash  locally,  cause  them  rapidly  to  disappear.  Superficial 
glossitis  and  the  superficial  and  deep  ulcerations  have  already 
been  described.  Gummata  occur  as  hard,  globular  masses  in  the 
fibrous  tissue  of  the  septum,  and  also  in  the  substance  of  the 
muscles.  They  may  be  single  or  multiple.  The  mucous  mem- 
brane covering  them  is  at  first  natural  in  appearance,  but,  as  the 
gumma  softens,  it  gives  way,  and  a  deep  syphilitic  ulcer  is  pro- 
duced.    Iodide  of  potassium  is  the  remedy. 

Excision  of  the  tongue  may  be  performed  in  many  ways. 
Only  those  methods  in  most  general  use  will  be  here  described. 
They  will  be  considered  under  the  heads  of,  excision  with  (i) 
the   knife,  (2)   the    ecraseur,  (3)  the   scissors,  (4)   the  galvano- 

cautery.  The  tongue  is  also 
frequently  excised  simultan- 
eously with  infiltrated  glands 
through  an  incision  in  the  side 
of  the  neck  by  (5)  Kocher's 
method. 

1.  Excision  with  the  knife, 
on  account  of  the  profuse 
haemorrhage  which  attends  it, 
is  only  applicable  when  the  an- 
terior portion  of  the  tongue 
requires  removal.  The  tongue 
should  be  well  drawn  forward 
and  the  diseased  portion  cut 
away  with  one  sweep  of  the 
knife,  and  the  bleeding  vessels 
tied. 

2.  The  ecraseurx'a  much  less 


Fig.  236. 


.^* 


/ 


Excision  of  the  tongue  with  the  i-craseur. 


used  than  formerly.  The  mouth  having  been  widely  opened  by 
a  gag,  two  ligatures  are  i)assed  through  the  tongue,  one  on  either 
side  of  the  tip,  and  the  mucous  membrane,  where  it  is  reflected 
from  the  tongue  to  the  jaw,  is  divided  with  scissors  along  with 


EXCISION   OF   THE   TONGUE.  525 

some  of  the  fibres  of  the  genio-hyo-glossus.  The  mucous  mem- 
brane covering  the  dorsum  ot  the  tongue  'is  next  divided  in  the 
middle  line  by  a  bistoury  from  the  tip  as  far  back  as  to  be  well 
beyond  the  disease.  This  allows  the  tongue  to  be  readily  spht 
with  the  fingers  into  two  halves.  The  cord  of  the  ecraseur  is  now 
passed  over  one- half,  and  well  behind  the  disease,  and,  if  the 
whole  tongue  is  to  be  removed,  the  cord  of  a  second  ecraseur 
over  the  other  half.  The  cord  being  tightened  by  screwing  up 
the  ecraseur,  the  tongue  is  cut  through.  The  lingual  artery,  with 
the  gustatory  nerve,  is  drawn  out  in  the  form  of  a  loop  by  the 
cord  of  the  ecraseur  (Fig.  236).  A  ligature  should  be  passed 
round  the  artery  with  an  aneurysm  needle,  and  the  artery  severed 
in  front  of  the  ligature.  The  anterior  part  of  the  tongue  will  now 
come  away,  leaving  the  ligature  on  the  artery  in  the  stump  of  the 
tongue.  The  above  is  a  sUght  modification  of  the  operation  in- 
troduced by  Mr.  Morrant  Baker. 

3.  Excision  with  the  scissors  (Whitehead's  method),  consists 
in  drawing  the  tongue  well  forward  by  two  ligatures  through  its  tip, 
dividing  the  frsenum,  splitting  the  tongue  as  described  above,  and 
then  separating  the  diseased  half  from  its  attachments,  beginning 
from  below  by  a  series  of  short  snips  with  blunt-pointed  scissors, 
clamping  or  tying  the  lingual  artery,  if  seen,  before  it  is  divided, 
or  else  immediately  it  is  cut.  The  lingual  artery  lies  immediately 
below  the  muscle-substance  about  a  quarter  of  an  inch  from  the 
middle  line.  If  the  disease  involves  both  sides  of  the  tongue  the 
opposite  half  can  next  be  removed  in  the  same  way.  To  prevent 
haemorrhage  during  the  operation,  some  Surgeons  first  tie  the  lin- 
gual artery  in  the  neck,  whilst  others,  for  fear  of  blood  entering 
the  trachea,  perform  tracheotomy,  and  plug  the  trachea  with 
Hahn's  tampon  cannula,  or  merely  introduce  an  ordinary  trache- 
otomy tube,  and  plug  the  pharynx  firmly  with  a  sponge  during 
the  operation.  All  such  measures  are,  however,  in  my  opinion 
quite  unnecessary,  and  only  add  to  the  danger  of  the  operation. 
Should  bleeding  occur  it  can  always  be  arrested  temporarily  by 
merely  passing  the  finger  into  the  pharynx  and  pressing  the  tongue 
against  the  inner  surface  of  the  jaw,  and  then  as  soon  as  the  mouth 
has  been  sponged  clear  of  blood  the  bleeding  vessel  can  be  seized 
and  tied.  Or  Lockwood's  clamp  for  compressing  the  lingual 
artery  may  be  used  during  the  operation  if  the  Surgeon  is  at  all 
nervous  of  bleeding,  the  only  objection  to  it  being  that  it  is  apt  to 
get  a  little  in  the  operator's  way.  Some  Surgeons  operate  with 
the  head  hanging  over  the  end  of  the  table,  so  that  the  blood  may 
not  run  down  into  the  throat.  When  Hahn's  cannula  is  used  it 
is  often  kept  in  for  several  days  after  the  operation,  for  the  pur- 
pose of  excluding  septic  discharges  from  the  air-passages  and  so 


526  DISEASES   OF   REGIONS. 

preventing  septic  pneumonia.  The  advantages  of  the  scissors 
over  the  ecraseur  are  that  a  cleaner-cut  surface  is  left  and  conse- 
quently that  the  Surgeon  can  be  more  certain  of  having  removed 
the  whole  of  the  disease,  that  less  sloughing  occurs,  and  that  the 
operation  is  more  quickly  performed.  Where,  however,  the 
tongue  is  adherent  to  the  floor  of  the  mouth  and  hence  cannot  be 
drawn  forward,  or  the  mouth  cannot  be  opened  sufficiently  wide, 
or  the  light  is  bad,  or  a  reliable  assistant  is  not  at  hand,  removal 
with  the  scissors  is  attended  with  considerable  difficulty,  and 
under  these  circumstances  removal  with  the  ecraseur  will  be  found 
safer.  As  regards  the  amount  of  sloughing,  I  am  not  convinced 
that  more  attends  the  use  of  the  ecraseur  than  the  scissors,  and  if 
care  is  taken  to  pass  the  cord  of  the  ecraseur  well  beyond  the  dis- 
ease, as  complete  a  removal  can  be  ensured. 

4.  Excision  with  the  galvano-cautery  is  strongly  recommended 
by  some  Surgeons,  but  is  open  to  the  serious  objection  that  it  is 
liable  to  be  followed  by  secondary  haemorrhage  on  the  separation 
of  the  sloughs. 

Whatever  operation  is  undertaken,  it  will  be  facilitated  when 
the  disease  is  far  back  by  splitting  the  cheek  from  the  angle  of 
the  mouth  to  the  masseter  muscle ;  whilst,  if  the  disease  has  in- 
vaded the  bone,  the  lower  lip  may  be  vertically  divided  in  the 
middle  line,  the  incision  continued  on  each  side  for  a  short 
distance  along  the  lower  border  of  the  ramus  of  the  jaw,  the  soft 
parts  dissected  up,  and  the  infiltrated  bone  removed  by  the  saw 
or  bone-pliers.  Division  of  the  lower  jaw  in  the  middle  line  and 
separation  of  the  two  halves  is  a  useful  procedure  when  the  floor 
of  the  mouth  is  implicated  and  the  disease  extends  far  back.  The 
jaw  should  be  united  at  the  conclusion  of  the  operation  by  silver 
wire  or  by  ivory  pegs. 

5.  Kocher's  operatio?t. — This  is  an  exceedingly  useful  method 
of  excising  one-half  of  the  tongue  with  the  infiltrated  glands 
when  the  disease  extends  far  back  and  is  limited  to  one  side  of 
the  organ.  Make  an  incision  from  the  mastoid  process  to  the 
hyoid  bone,  and  thence  to  the  symphysis  of  the  jaw.  Divide  the 
platysma ;  tie  the  facial  artery  ;  extirpate  the  submaxillary  lym- 
phatic glands,  and  especially  the  gland  over  the  carotid  sheath ; 
tie  the  lingual  artery  where  it  dips  behind  the  hyo-glossus  ;  extir- 
pate the  submaxillary  salivary  gland  ;  divide  the  mylo-hyoid  mus- 
cle ;  remove  the  sublingual  gland,  and  cut  through  the  mucous 
membrane  of  the  floor  of  the  mouth.  The  tongue  will  now  be 
exposed  as  far  as  its  root ;  split  it  down  the  middle  line,  draw 
the  affected  half  out  of  the  wound,  and  sever  it  from  its  connec- 
tions well  behind  the  disease  with  scissors. 

During  the  removal  of  the  tongue  chloroform  should  be  admin- 


CLEFT   PALATE.  527 

istered  by  a  tube  passed  through  the  nose  (Junker's  method), 
or  if  tracheotomy  is  performed  and  the  trachea  plugged,  through 
the  cannula. 

The  after-treatment  coxi'ii'iX?,  in  dusting  the  stump  with  iodoform, 
or  painting  it  with  Whitehead's  iodoform  varnish,  packing  the 
mouth  with  iodoform  gauze,  or  frequently  syringing  it  with 
Condy's  fluid  or  other  antiseptic  lotion.  Some  Surgeons  recom- 
mend feeding  with  a  tube  passed  through  the  mouth  or  nose  for 
the  first  few  days,  or  by  the  rectum.  The  nasal  tube,  however,  is 
often  a  source  of  great  irritation,  and  feeding  is  better  accom- 
plished by  a  spoon  or  "feeder"  passed  well  to  the  back  of  the 
mouth.  It  is  well  to  leave  a  ligature  through  the  stump  of  the 
tongue,  so  that  should  recurrent  hsemorrhage  occur,  the  stump  may 
be  drawn  forwards  and  the  bleeding  vessel  more  easily  secured. 

DISEASES    OF    THE    UVULA,  PALATE,  FAUCES    AND    TONSILS. 

UvuLiTis,  or  inflammation  of  the  uvula,  is  a  frequent  accom- 
paniment of  pharyngeal  catarrh.  The  uvula  appears  red,  swollen 
and  oedematous,  and  often  considerably  elongated.  If  the  mflam- 
mation  does  not  yield  to  the  remedies  employed  for  the  catarrh, 
scarification  should  be  practiced. 

Elongation  of  the  uvula  may  depend  upon  chronic  catarrh 
of  the  pharynx,  or  upon  conditions  similar  to  those  leading  tp 
chronic  enlargement  of  the  tonsils.  The  elongated  uvula  may 
come  into  contact  with  the  back  of  the  tongue  or  even  with  the 
mucous  membrane  of  the  larynx,  and  in  either  case  is  productive 
of  a  troublesome  tickling  cough.  If  astringents  fail,  the  end  of 
the  uvula  may  be  amputated. 

Cleft  palate  is  a  congenital  defect  due  to  an  arrest  of  devel- 
opment of  the  processes  which  normally  grow  inwards  from  the 
superior    maxillary    and    palate    bones,    and 
meeting   each   other   and    the  vomer  in   the  Fig.  237. 

middle   line,    and    the   premaxillary  bone   in 
front,  form  the  hard  and  soft  palate.     This  ar- 
rest of  development    may   be   complete,   the 
fissure  extending  in  the  middle  hne  through 
the  uvula  and   the   soft  and  hard  palate,  and 
hence  through  the  alveolar  process  in  the  line 
of  suture  either  on  one  or  both  sides  of  the 
premaxillary  bone  (Fig.  237).     It  will  in  this 
case  be   generafly  combined  with    double  or       the  hard  paiate.""^^  '" 
single  hare-lip  respectively.     When  the  arrest 
is  only  partial,  the  cleft  may  extend  through  the  uvula  alone,  or 
through  the  soft  palate  as  well,  or  through  the  soft  palate  and  part 
of  the  hard ;  whilst  in  other  instances  the  alveolar  process  only  on 


528  DISEASES   OF    REGIONS. 

one  or  both  sides  of  the  middle  line  may  be  notched,  as  occurs  so 
often  in  hare-lip.  The  vomer,  which  is  continuous  in  front  with 
the  premaxillary  bone,  either  presents  a  free  border  in  the  middle 
of  the  cleft,  or  is  attached  to  one  or  other  margin  of  the  cleft. 
The  cojisequeiiccs  of  cleft  palate  vary  with  the  age  of  the  patient 
and  extent  of  the  cleft.  In  infoncy,  suction  and  deglutition  are 
seriously  interfered  with  ;  whilst  later,  the  voice,  articulation,  taste, 
smell,  and  hearing,  may  all  be  impaired. 

Treatment. — The  infant,  if  unable  to  take  the  breast  in  an 
erect  or  semi-recumbent  posture,  must  be  fed  with  the 
mother's  milk  by  a  spoon  passed  well  to  the  back  of  the 
mouth,  or  by  a  feeding-bottle  with  a  large  teat  to  act  as  a  plug  to 
the  cleft.  The  operation  for  the  cure  of  the  deformity  should  be 
undertaken  before  the  child  begins  to  speak,  which  is  generally 
about  a  year  later  than  usual  ;  but  not  in  infancy,  as  bleeding  is 
then  badly  borne,  and  the  cleft  of  the  bony  palate  diminishes  in 
width  during  the  first  three  years  of  life.  Infants,  moreover,  are 
very  hable  to  such  ailments  as  catarrh  of  the  pharynx  and  lungs, 
and  coughing  and  sneezing  tend  to  tear  the  parts  asunder.  The 
cleft  in  the  hard  and  soft  palate  should  be  closed  at  the  same 
time.     Hare-hp,  if  present,  should  be  operated  on  in  infancy. 

Staphylorraphy  or  closure  of  the  soft  palate.  Chloroform  hav- 
ing been    given   by   Junker's   apparatus   with   the   tube   passed 

through    the    nose,   and    the    mouth 

Fig.  2^8.  widely   opened    by   a    Smith's    gag, 

which    depresses   the    tongue    at    the 

same  time  (Fig.  238),  one  end  of  the 

bifid  uvula  is  seized  with  long  forceps, 

and  the  edge  of  the  cleft  pared  from 

below  upwards,   and    the   paring   re- 

^  peated   on    the   opposite   side.     The 

c„;,. ..  „,„  r      ,  .,     ,  ,       . .      uvula  and  the  lower  part  of  the  palate 

bmitn  s  gag   for  cleft   palate,  with  ,'■  . ' 

key.  are   then   united  with    horsehair,   the 

upper    part    with    silver    wire.     The 

wire   sutures  are  best  passed  by  Smith's  needle,  by  which  they 

can   be  carried  through  both  sides  of  the  cleft  by  one  transit 

of  the  needle.     This  needle,  shown  in  Fig.  239,  has  "a  small  reel 

Fig.  239. 


.Smith's  needle  for  passing  wire  sutures  in  cleft  palate. 

attached  behind  the  handle  to  hold  the  wire,  and  a  small  serrated 
wheel  half  way  up  the  handle  to  protrude  the  wire  from  its  tubu- 


CLEFT   PALATE.  529 

lar  point."     The  horsehair  may  be  passed  across  the  cleft  by  the 
needle  shown  in  Fig.  240,  and  as  the  point  of  the  needle  pro- 

FiG.  240. 

I 


Smith's  palate  needle  for  passing  horsehair  sutures  in  cleft  palate. 

trudes  from  the  palate,  the  end  of  the  horsehair  is  seized  and 
drawn  out  by  nibbed  palate  forceps  or  by  the  suture-catcher 
(Fig.  241),  and  the  needle  withdrawn.     The  silver  sutures  should 

Fig.  241. 


Suture-catcher. 

be  fastened  by  the  wire  twister  (Fig.  242)  and  cut  off  short,  care 
being  taken  to  hold  the  edges  of  the  cleft  merely  in  apposition  and 
not  to  apply  any  tension.  The  horsehair  should  be  tied  with  a 
treble  Surgeon's  knot.  When  the  parts  have  been  brought  to- 
gether any  undue  tension  should  be  relieved  by  making  lateral  in- 
cisions through  each  side  of  the  soft  palate  parallel  to  the  cleft 
and  just  internal  to  the  hamular  process,  with  a  tenotome  on  a 
long  handle.  By  these  incisions  the  levator  palati  muscles  are 
divided.  The  palato-pharyngei  may  also  be  divided  if  neces- 
sary by  notching  the  posterior  pillars  of  the  fauces  with  scissors. 

Fig.  242. 


Wire-twister. 

Uranoplasty,  or  closure  of  the  hard  palate.  The  soft  palate 
having  been  previously  brought  together  in  the  way  described, 
the  operation  on  the  hard  may  be  begun  at  that  stage  where  the 
tension  becomes  such  that  the  soft  parts  can  no  longer  be  brought 
together.  The  edges  of  the  cleft  having  been  pared,  an  incision 
from  a  quarter  to  three-quarters  of  an  inch  long  should  be  made 
on  either  side  of,  and  parallel  to,  the  cleft  through  the  muco- 
periosteum  down  to  the  bone  (Fig.  243  e,  e).  The  incisions 
should  fall  a  little  distance  from  the  alveolar  process,  so  as  to 
avoid  wounding  the  anterior  palatine  artery.  Into  one  of  these 
23 


530 


DISEASES   OF   REGIONS. 


Fig.  243. 


incisions  a  raspatory  or  an  aneurysm  needle  with  a  short  curve 
should  be  introduced,  and  the  muco-periosteum  separated  from 
the  bone  along  the  whole  length  of  the  cleft  in  the  hard  palate, 
avoiding  the  neighborhood  of  the    posterior   palatine    foramen 
through  which  the  anterior  palatine  artery 
nms.     The    attachment    of    the    muco- 
periosteum  to  the  posterior  margin  of  the 
hard    palate    should    be    divided    with 
curved  scissors  passed  through  the  cleft 
and  behind  the  soft  palate,  which  should 
be  drawn  forwards  to  facilitate  this  step 
of   the   operation.     Pressure   should   be 
made  upon  the  parts  with  a  small  sponge 
by     an     assistant,     whilst     the     muco- 
periosteum   is   being   separated    in    like 
manner  on  the  opposite  side.     Wire  su- 
tures should  now  be  passed  in  the  way 
described  for  uniting  the  soft  palate,  and 
any  tension  relieved  by  prolonging  the 
cuts  made    for   the  introduction  of  the 
raspatory  forwards  or  backwards,  as  the 
case  may  require.     Haemorrhage,  though 
often  sharp,  is  seldom  severe,  and  may 
generally    be    stopped    by   pressure    or 
syringing  with  ice-cold  water,  the  head  being  turned  over  to  one 
side  to  let  the  blood  escape,  or  if  it  becomes  serious,  by  plugging 
t  V  /...M^he  posterior  palatine  canal  with  a  small  peg  of  wood. 

,^^^^^  After-treatment. — The  patient  should  be  fed  on  iced  milk  for 
'  the  first  few  days,  and  then  on  soft  food  for  a  fortnight.  The 
sutures  may  be  left  in  for  three  weeks  or  a  month  ;  if  the  patient 
is  unruly  they  should  be  removed  under  chloroform.  The  cleft 
ought  to  heal  by  the  first  intention,  and  the  lateral  cuts  for  taking 
off  tension,  by  granulation.  If  a  portion  of  the  cleft  fails  to  unite 
by  the  first  intention  it  will  often  heal  up  subsequently  by  granu- 
lation ;  if  not,  a  second  ojjcration  must  be  undertaken.  It  is 
somewhat  doubtful  whether  the  muco-periosteum  ossifies. 

Necrosis  of  the  hard  palate  is  generally  due  to  the  breaking 
down  of  syphilitic  gummata,  and  is  followed  by  perforation  and  at 
times  by  destruction  of  the  greater  part  of  the  hard  and  soft 
palates,  and  septum  of  the  nose.  Ti-eatment. — Large  doses  of 
iodide  of  potassium,  and  when  the  ulceration  has  ceased,  an  ob- 
turator to  close  the  perforation,  and  later  a  plastic  operation  if 
practicable. 

Acute  'jonsii.i.ius  may  be  the  result  of  taking  cold  in  a  person 
in  feeble  health,  or  the  subject  of  the  rheumatic  diathesis,  or  who 


Position  of  the  lateral  incisions, 
E,  E,  through  the  muco-peri- 
osteum, in  the  operation  for 
cleft  of  hard  palate.  The 
dotted  line  indicates  the  line 
of  junction  of  the  hard  and 
soft  palate.  (Bryant's  Sur- 
gery.) 


CHRONIC   ENLARGEMENT   OF   THE   TONSILS.  53 1 

from  previous  attacks  has  become  predisposed  to  the  disease ; 
sometimes  it  is  due  to  septic  poisoning,  as  from  the  inhalation  of 
sewer  gas ;  or  it  may  occur  in  the  course  of  other  diseases,  as 
scarlet  fever.  Sig/is. — It  generally  begins  with  a  slight  chill,  or 
even  a  rigor,  followed  by  high  temperature,  furred  tongue,  offen- 
sive breath,  salivation,  pain  darting  to  the  ear  and  increased  on 
SAvallowing,  and  swelling  of  the  glands  behind  the  angle  of  the 
jaw.  If  the  mouth  can  be  sufficiently  opened,  one  or  both  of  the 
tonsils  are  found  to  be  red  and  swollen,  and  often  in  contact, 
blocking  up  the  fauces.  The  neighboring  parts  are  congested 
and  swollen,  and,  in  the  variety  known  as  foUiadar  tonsillitis,  a 
secretion  is  seen  oozing  from  the  mouths  of  the  inflamed  follicles. 
The  inflammation  may  now  subside,  or  terminate  in  suppuration 
{quinsy),  which  may  be  known  by  the  pain  becoming  of  a  throb- 
bing character,  and  a  sense  of  fluctuation  or  softening  on  palpa- 
tion. Treatment. — At  the  onset  a  sharp  purge  should  be  given, 
whilst  large  doses  of  perchloride  of  iron,  quinine,  or  salicylate  of 
soda,  with  local  insufflations  of  bicarbonate  of  soda,  may  be  tried 
as  abortives.  Where  suppuration  threatens,  the  throat  should  be 
steamed,  and  hot  camomile  mattresses  or  linseed  poultices  applied 
externally.  As  soon  as  the  abscess  has  formed,  an  incision  should 
be  made  with  a  bistoury,  guarded  by  wrapping  it  round  with 
sticking-plaster  to  within  half  an  inch  from  the  end,  and  directing 
the  point  towards  the  middle  line  to  avoid  injuring  the  tonsillar 
arteries  and  the  internal  carotid. 

Chronic  enlargemfnt  of  the  tonsils  consists  of  an  hyper- 
trophy of  the  normal  tissue  of  the  tonsil,  and  is  very  common  in 
strumous  children,  in  whom  it  is  frequently  associated  with 
adenoid  growths  in  the  vault  of  the  pharynx.  At  times  it  appears 
due  to  oft-repeated  attacks  of  acute  tonsillitis.  The  symptotns  to 
which  it  may  give  rise  are  :  a  nasal  tone  of  voice  ;  a  peculiar 
vacant  expression,  acquired  by  the  child  constantly  breathing  with 
the  mouth  half  open  ;  regurgitation  of  fluids  through  the  nose  ; 
snoring  during  sleep ;  distressing  dreams,  from  the  imperfect 
aeration  of  the  blood  ;  and  recurring  attacks  of  acute  or  sub-acute 
tonsillitis ;  whilst  deafness,  from  implication  of  the  Eustachian 
tube  and  middle  ear  in  the  chronic  inflammation,  may  sometimes 
be  induced,  and  even  an  alteration  in  the  shape  of  the  chest,  and 
possibly  phthisis.  The  tonsils  appear  irregularly  enlarged,  often 
almost  blocking  up  the  fauces,  but,  unless  inflamed,  of  a  natural 
color,  or  perhaps  slightly  paler  than  natural.  Treatment. — In 
young  children  the  affection  may  be  cured  by  persistent  painting 
with  the  tincture  of  perchloride  of  iron  or  tincture  of  iodine,  com- 
bined with  the  internal  use  of  cod-liver  oil  and  syrup  of  the  phos- 
phate or  the  iodide  of  iron.     In  older  children,  or  where  the 


532  DISEASES   OF   REGIONS. 

tonsils  are  much  enlarged,  they  should  be  excised,  either  with  the 
knife,  or  better  with  the  guillotine  (Fig.  244),  and  this  should  be 

done  before  the  voice  has  be- 
come seriously  affected  or  other 
mischief  has  ensued.  The 
''^=^'~"''"'-°»""^  ^      hcemorrhage      attending      the 

Tonsil  guillotine.  Operation,  though  usually  slight, 

has  at  times  been  alarming. 
GargHng  with  cold  water  will  generally  stop  it ;  but  if  this  fails, 
ice,  or  astringents,  as  tannic  acid,  or  pressure  with  a  pencil 
guarded  with  lint,  will  nearly  always  succeed.  Should  a  bleeding 
vessel  be  seen,  it  should  be  tied  or  twisted.  In  exceptional-  cases, 
the  common  carotid  has  had  to  be  tied.  Should  adenoid  growths 
be  present  they  should  be  removed  at  the  same  time  as  the  tonsils. 

Ulceration  of  the  fauces,  palate,  and  tonsils  may  be  simple, 
gangrenous,  syphilitic,  tubercular,  or  malignant. 

Simple  iilceration,  the  so-called  ulcerated  sore  throat,  is  gen- 
erally the  result  of  debility,  induced  by  over-work  in  a  close  at- 
mosphere, and  hence  is  frequent  in  workers  in  hospital  wards, 
where  it  is  known  as  hospital  sore-throat.  Change  of  air,  a 
nourishing  diet,  quinine  and  port  wine,  with  a  gargle  of  chlorate 
of  potash,  will  usually  relieve  it.  If  neglected  it  may  assume  a 
gangrenous  form,  and  extensive  sloughing  may  then  ensue,  with 
constitutional  symptoms  of  blood-poisoning,  which  often  proves 
rapidly  fatal.  Stimulants  and  fluid  nourishment  should  be  fre- 
quently administered,  and  quinine,  perchloride  of  iron,  or  am- 
monia and  bark,  given  internally.  Tracheotomy,  if  the  larynx 
becomes  involved,  may  be  necessary. 

Syphilitic  ulceration  may  be  superficial  or  deep.  The  superficial 
ulcers  are  common  in  the  early  stages  of  syphilis,  and  may  be  ac- 
companied by  mucous  tubercles.  Deep  ulcers,  due  to  the  break- 
ing down  of  gummata,  occur  in  the  later  stages  as  irregular 
excavations  with  sharply-cut  edges  and  a  sloughy  base,  but  are 
unattended  with  induration.  On  healing  they  are  often  produc- 
tive of  much  contraction  (see  Pharyngeal  Stenosis). 

The  so-called  tubei-cular  ulceration  occurring  in  strumous  chil- 
dren bears  a  general  resemblance  to  the  syphilitic,  and  is  believed 
by  some  to  be  really  the  result  of  congenital  syphilis.  Like  the 
syphilitic,  it  may  lead  to  extensive  destruction  of  the  parts. 

Malignant  ulceration  is  due  to  the  breaking  down  of  epithelio- 
matous  and  sarcomatous  growths.  It  may  be  known  by  the 
sinuous,  everted,  and  indurated  edges  of  the  ulcer,  and  other 
signs  of  malignancy. 

'J'uMOkS  ok  'ihe  'jonsil. — Sarcoma  and  epithelioma  occasionally 
occur  in  the  tonsil.     They  grow  rapidly,  soon  affect  the  lym- 


EPULIS.  533 

phatic  glands  in  the  neck,  and  extend  to  surrounding  parts.  Un- 
less detected  and  removed  whilst  they  are  quite  small  and 
localized  to  the  tonsil,  they  are  beyond  the  reach  of  surgery. 
Other  tumors  in  this  region  are  rare. 

DISEASES  OF   THE  GUMS  AND  JAWS. 

Hypertrophy  of  the  gums  has  been  observed  as  a  congenital 
affection,  and  may  be  met  with  where  there  is  overcrowding  of  the 
teeth  as  a  lobulated  fringe -like  growth  of  the  gums,  which,  in  se- 
vere cases,  may  so  surround  the  teeth  that  they  appear  as  if  buried 
in  it.  The  hypertrophied  portion  should  be  shaved  off,  and  one 
or  more  of  the  teeth  extracted. 

Polypi  of  the  gums,  as  they  are  called,  are  merely  overgrowths 
of  the  httle  tongue  of  gum  between  the  teeth,  and  appear  gener- 
ally to  depend  on  the  presence  of  tartar  or  caries.  The  offending 
tooth  should  be  scaled,  stopped  or  extracted,  and  the  growth  cut 
off. 

Papillomata,  or  warty  growths,  occasionally  occur  on  the  gums. 
They  are  generally  pedunculated,  and  can  be  readily  snipped  off 
with  scissors. 

Spongy  gums  may  occur  as  the  result  of  scurvy  or  the  abuse  of 
mercury,  and  are  sometimes  met  with  in  strumous  children.  The 
condition  is  often  associated  with  superficial  ulceration.  The 
treatme7it  consists  in  the  removal  of  the  cause,  the  use  of  an 
astringent  mouth-wash,  and  the  constitutional  remedies  appropri- 
ate to  scurvy  or  struma. 

Alveolar  abscess  may  be  quite  superficial  {gum-boil)  and 
merely  require  a  slight  prick ;  or  it  may  form  around  the  fang  of 
a  carious  tooth,  and  then  either  make  its  way  to  the  surface  by 
the  side  of  the  tooth,  or  expand  the  alveolus  and  perforate  the 
bone.  In  the  latter  case  it  may  track  below  the  reflexion  of  the 
mucous  membrane  from  the  gums  to  the  cheek,  and  point  about 
the  angle  of  the  jaw  or  on  the  cheek,  and  after  opening  leave  an 
intractable  sinus.  In  the  upper  jaw  it  sometimes  also  tracks  along 
the  hard  palate,  and  may  lead  to  necrosis  of  the  bone.  It  is  at- 
tended with  severe  throbbing  pain,  deep-seated  swelling,  and  often 
great  oedema  of  the  face  and  eyehd.  Treatment. — The  offending 
tooth  should  be  extracted,  hot  fomentations  and  bread-poultices 
applied  inside  the  mouth,  and  the  sinus  divided  transversely  from 
within  the  mouth  to  prevent  an  external  opening  being  formed. 
If  a  sinus  exists  the  carious  tooth  or  dead  bone  must  be  removed 
before  it  will  heal ;  scraping  the  sinus  will  then  facilitate  the 
healing. 

Epulis. — This  term,  though  formerly  employed  to  signify  any 


534  DISEASES   OF   REGIONS. 

tumor  growing  upon  the  gums,  is  now  usually  restricted  to  the 
variety  that  was  then  distinguished  as  the  fibrous  or  common 
epulis.  An  epulis  consists  principally  of  fibrous  tissue,  but  may 
sometimes  contain  a  few  myeloid  cells.  It  frequently  appears  to 
depend  upon  the  irritation  of  a  carious  stump,  and  springs  from 
the  periodontal  membrane  lining  an  alveolus.  Beginning  as  a 
swelling  of  the  little  tongue-like  process  of  gum  between  the  teeth, 
as  it  increases  in  size  it  appears  as  a  hard,  fleshy,  circumscribed, 
smooth  or  slightly  lobulated  elastic  growth,  covered  by  mucous 
membrane.  When  it  has  existed  some  time  ulceration  of  the  sur- 
face may  occur,  and  one  or  more  teeth  become  loosened  or  fall 
out.  Treatment. — It  should  be  excised  with  bone  forceps  or  a 
small  saw,  care  being  taken  to  cut  away  a  small  piece  of  the  bone 
beneath,  as  otherwise  it  is  apt  to  return.  When  quite  small  it 
may  be  shaved  off,  a  thin  layer  of  the  bone  at  its  base  gouged 
away,  and  the  offending  tooth  or  teeth  removed. 

Myeloid  sarcoma  {myeloid  epulis)  is  occasionally  met  with  on 
the  gums  as  a  rapidly-growing  vascular  tumor  of  a  purplish-red 
color  and  soft  spongy  consistency.  It  should  be  very  freely  re- 
moved with  the  underlying  bone,  as  otherwise  it  will  return.  The 
hemorrhage  during  removal  is  generally  free,  and  may  require  the 
actual  cautery  to  restrain  it. 

Epuhelioma  {malignant  epulis)  of  the  gums  is  rare.  In  the 
upper  jaw  it  has  a  marked  tendency  to  creep  up  into  the  antrum 
{creeping  epithelioma^  and  to  simulate  caries  or  necrosis  of  the 
jaw.  Free  excision,  with  removal  of  the  upper  jaw  if  the  antrum 
is  involved,  should  be  undertaken  if  there  is  a  fair  chance  of  get- 
ting the  whole  of  the  disease  away  and  the  glands  are  not  much 
involved. 

Inflammation  and  abscess  of  the  antrum  is  generally  due  to 
the  irritation  of  the  fiing  of  a  carious  tooth.  It  is  attended  with 
deep-seated  pain,  followed  by  swelling,  f«dema,  heat,  and  redness 
of  the  cheek  and  lower  eyelid,  and  when  very  acute,  by  sharp 
constitutional  disturbance.  The  pus  may  overflow  into  the  nose, 
or  escape  by  the  side  of  a  tooth  ;  or,  in  other  instances,  may  dis- 
tend the  cavity  and  cause  the  bony  walls  to  bulge.  The  treatment 
consists  in  providing  a  free  exit  for  the  pus  as  soon  as  formed, 
either  by  removing  the  carious  tooth  and  perforating  the  antrum 
through  the  bottom  of  the  alveolus,  or,  if  the  teeth  are  sound,  by 
perforating  the  anterior  wall  within  the  mouth  through  the  canine 
fossa.   The  cavity  should  then  be  kept  aseptic  by  antiseptic  lotions. 

Closure  of  the  jaws  is  the  term  applied  to  a  condition  in 
which  the  lower  jaw  cannot  be  oj^ened,  at  least  not  to  any  extent. 
It  may  be  due  to — i,  spasm  of  the  masseter  muscle,  consequent 
upon  the  iritation  attending  the  eruption  of  a  wisdom-tooth  for 


NECROSIS    OF    THE    JAWS.  535 

which  there  is  not  room;  2,  cicatricial  contraction,  following 
ulceration  of  the  mucous  membrane  induced  by  cancrum  oris, 
syphiHs,  lupus,  the  abuse  of  mercury,  etc. ;  3,  ankylosis  of  the 
temporo-maxillary  joint ;  and  4,  hysteria.  Treatment. — When 
dependent  upon  the  eruption  of  a  wisdom-tooth,  the  tooth  itself, 
or  under  some  circumstances  the  second  molar,  must  be  extracted. 
When  dependent  upon  cicatricial  contractions,  the  forcible  open- 
ing of  the  mouth  by  a  screw-gag  and  maintaining  it  open  by  a  cork 
placed  between  the  teeth  will,  in  slight  cases,  suffice.  In  other 
instances  I  have  found  division  of  the  cicatricial  bands,  and  sub- 
sequently keeping  the  jaws  separated,  successful,  although  this 
proceeding  does  not  appear  to  have  always  answered  in  the  hands 
of  others.  When  the  bands  are  very  dense  or  the  closure  depends 
upon  ankylosis  of  the  temporo-maxillary  joint,  a  new  articulation 
must  be  made  by  dividing  the  ramus  of  the  jaw  and  removing  a 
wedge-shaped  piece  of  bone  in  front  of  the  cicatricial  contractions. 
Necrosis  of  the  jaws. — Necrosis  is  more  common,  and  when 
it  occurs,  more  extensive  in  the  lower  than  in  the  upper  jaw,  a 
fact  due  in  part  to  the  poorer  blood-supply  of  the  former,  and  in 
part  to  the  predilection  of  necrosis  for  compact  rather  than  for 
cancellous  bone.  Though  the  necrosis  may  affect  the  whole  of 
the  jaw,  it  is  more  often  limited  to  the  alveolar  process  or  to  the 
anterior  wall.  The  teeth  may  loosen  and  fall  out ;  but  at  times^ 
they  retain  their  connection  with  the  gums  and  remain  in  situ 
after  the  removal  of  the  sequestrum.  The  causes  of  necrosis  of 
the  jaw,  as  of  necrosis  elsewhere,  generally  depend  upon  inflam- 
mation of  the  periosteum  or  bone,  which  in  the  case  of  the  jaw 
appears  especially  to  be  induced  by  the  fumes  of  phosphorus,  the 
abuse  of  mercury,  carious  teeth  in  strumous  subjects,  syphilis,  the 
exanthemata,  cancrum  oris,  and  lastly,  injury,  as  in  extracting  a 
tooth.  Phosphorus-necrosis  is  generally  believed  only  to  affect 
the  subjects  of  carious  teeth,  but  some  maintain  that  it  is  a  local 
manifestation  of  a  general  phosphorus-poisoning.  It  is  much  less 
common  since  the  amorphous  form  of  phosphorus  has  been  used 
for  making  matches.  The  production  of  new  bone  in  necrosis  of 
the  lower  jaw  is  generally  extensive  ;  and  there  are  several  speci- 
mens in  St.  Bartholomew's  Hospital  Museum  showing  almost 
complete  reproduction  of  the  whole  jaw.  In  the  upper  jaw  new 
bone  is  not  formed  after  complete  removal.  In  phosphorus- 
necrosis  a  characteristic  pumice-like  deposit  of  new  bone  is 
formed.  Symptoms. — Necrosis  generally  begins  with  severe  pain 
and  deep-seated  swelling,  which  may  at  first  be  mistaken  for 
toothache  or  alveolar  abscess,  followed  by  suppuration  and  burst- 
ing of  the  abscess,  either  in  the  mouth  or  externally  on  the  face, 
and  the  formation  of  sinuses.     The  breath,  as  a  rule,  is  horribly 


536  DISEASES   OF   REGIONS. 

foetid,  and  there  is  sharp  constitutional  disturbance,  which,  in 
phosphorus-necrosis,  is  sometimes  excessive,  and  may  end  in 
septicaemia  or  pyaemia.  On  probing  the  sinus,  dead  bone  is  de- 
tected. This  sign  will  usually  distinguish  necrosis  from  the 
creeping  form  of  epithelioma,  for  which,  especially  in  the  upper 
jaw,  it  is  apt  to  be  mistaken.  Trea/i/ieiif. — The  bone  as  soon  as 
loose  should  be  removed,  if  possible,  through  the  mouth.  In  the 
meantime  the  parts  should  be  kept  aseptic  by  syringing  with 
Condy's  fluid  or  carbolic  lotion,  or  by  insufflation  of  iodoform, 
incisions  being  made  through  the  periosteum  to  ensure  a  free 
drain,  or  Cargill's  respirator  may  be  worn  to  neutralize  the  foetor. 
Inteinally,  tonics  and  stimulants  and  nourishing  diet  should  be 
given,  and  iodide  of  potassium  if  there  is  a  syphilitic  taint. 

Tumors  of  the  upper  jaw  may  be  cystic  or  solid,  and  the 
latter  innocent  or  malignant ;  whilst  cysts  may  likewise  occur  in 
the  malignant  solid  tumors. 

Cystic  tumo7-s  may  be  produced  :  i.  In  connection  with  the 
fang  of  a  carious  tooth.  2.  By  an  error  in  development  of  the 
enamel  sac  covering  the  crown  of  a  tooth  {deutigcroiis  cysts)  ; 
and  3.  By  obstruction  of  a  mucous  follicle  in  the  lining  mem- 
brane of  the  antrum.  These  cysts  usually  contain  a  serous, 
gelatinous,  or  a  brownish  fluid  in  which  cholesterine  is  often 
found.  The  condition  known  as  dropsy  of  the  antrum,  and  form- 
erly believed  to  depend  merely  upon  an  accumulation  of  fluid  ni 
that  cavity  owing  to  the  occlusion  of  the  opening  into  the  nose, 
would  appear  to  be  due  to  one  of  these  mucous  cysts  completely 
filling  the  antrum. 

JDentigeroi/s  cysts,  which  may  also  occur  in  the  lower  jaw,  are 
due  to  an  error  in  the  development  of  the  enamel  sac,  usually  of 
the  permanent  teeth.  They  differ  from  the  ordinary  dental  cyst 
depending  upon  the  irritation  of  a  decayed  fang,  in  that  in  the 
latter  the  fang  will  generally  be  found  projecting  into  the  cyst, 
whereas  in  the  dentigerous  variety  the  crown  alone,  which  has 
not  been  cut,  or  in  some  cases  the  whole  tooth,  will  be  found  in 
the  cyst. 

So/id  tumors  may  spring  from  the  jjeriosteum  covering  the 
exterior  of  the  bone,  or  from  the  mucous  or  the  periosteal  lining 
of  the  antrum.  They  may  have  a  fibrous,  cartilaginous,  osseous, 
myxomatous,  adenomatous,  sarcomatous  or  carcinomatous  struc- 
ture ;  but  fibrous  and  sarcomatous  tumors  are  the  most  common, 
whilst  cartilaginous  are  very  rare.  Ossification  of  the  sarco- 
matous growths  is  of  occasional  occurrence.  They  may  be 
closely  simulated  by  tumors  of  a  like  diversity  of  structure  grow- 
ing from  the  malar  bone,  the  spheno-maxillary  fossa,  or  the  base 
of  the  skull. 


TUMORS    OF    THE    UPPER    JAW.  537 

Symptoms  and  Diagnosis. — Clinically,  it  is  not  always  possible 
to  determine  the  exact  structure  of  these  tumors,  nor  is  it  essen- 
tial, the  surgeon's  aim  being  rather  to  distinguish  the  solid  from 
the  fluid,  and  the  innocent  from  the  malignant,  and  to  make  out 
their  origin  and  present  attachments.  When  the  tumor,  whether 
cystic  or  solid,  innocent  or  malignant,  begins  in  the  antrum,  it 
sooner  or  later  fills  that  cavity,  and  then  in  its  further  growth 
causes  its  walls  to  bulge  in  various  directions.  Thus,  the  bulging 
of  the  anterior  wall  causes  a  swelling  on  the  cheek,  of  the  internal 
wall  an  obstruction  in  the  nose,  of  the  inferior  wall  a  depression 
of  the  palate,  and  of  the  superior  wall  a  protrusion  of  the  eye. 
A  rounded  projection  on  the  cheek;  a  sensation  of  fluctuation 
felt  through  the  anterior  wall  of  the  antrum  with  the  finger  in  the 
mouth,  or  egg-shell-like  crackling  produced  by  the  yielding  of  the 
thinned  and  partially  absorbed  walls ;  the  presence  of  a  carious 
tooth,  or  the  absence  of  one  of  the  teeth  in  the  series  (in  the  case 
of  a  dentigerous  cyst)  will  point  to  the  cystic  nature  of  the  swell- 
ing, and  puncture  with  a  trocar  and  cannula  will  clear  up  any 
doubt.  Should  the  tumor  be  solid,  it  will  probably  be  innocent  if 
of  slow  growth  and  there  be  absence  of  pain  and  glandular  en- 
largement, non-impHcation  of  the  skin,  and  non-infillration  of 
surrounding  parts  ;  but  malignant  if  of  rapid  growth  and  there  is 
severe  pain,  early  escape  through  the  walls  of  the  antrum,  impU- 
cation  of  the  skin,  involvement  of  glands,  and  protrusion  of  a 
fungous  mass  in  the  mouth,  nose,  or  on  the  cheek.  In  malignant 
disease,  moreover,  the  patient  will  probably  be  either  young  in  the 
case  of  sarcoma,  or  advanced  in  life  in  the  case  of  carcinoma,  but 
if  a  small  piece  of  the  growth  can  be  obtained,  a  microscopical 
examination  will  settle  the  point.  When  the  growth  springs  from 
the  malar  bone,  it  may  either  project  forwards  on  the  cheek,  or 
into  the  mouth  between  the  cheek  and  the  bone,  and  the  bulging 
of  the  walls  of  the  antrum  will  be  absent.  When  it  arises  from 
the  spheno-maxillary  fossa  or  base  of  the  skull,  it  will  commonly 
project  into  the  naso-pharynx,  where  it  may  be  detected  by  the 
finger  or  rhinoscope,  while  the  whole  maxillary  bone  will  be 
pushed  forward.  It  should  not  be  forgotten,  however,  that 
tumors  beginning  in  the  antrum,  especially  the  fibrous  and  sar- 
comatous, encroach  upon  the  surrounding  parts,  and  conversely, 
that  the  cavity  of  the  antrum  may  be  invaded  by  growths  not 
primarily  connected  with  it ;  so  that  when  a  tumor  in  this  region 
has  attained  a  large  size  it  may  be  impossible  to  determine  its 
origin,  or,  indeed,  the  whole  of  its  actual  attachments. 

Treatment. — For  cystic  tumors,  excision  of  a  portion  of  the 
wall  from  within  the  mouth  will  generally  sufiice,  if  a  free  drain  is 
subsequently  ensured.     At  times  the   thinned  walls  of  the  cyst 


538  DISEASES   OF   REGIONS. 

may  be  crushed  together  by  the  fingers  with  advantage.  Where 
the  cyst  is  associated  with  a  solid  growth,  the  latter  may  some- 
times be  scraped  away,  otherwise  the  upper  jaw  must  be  partially 
or  completely  removed.  Where  the  tumor  is  solid,  and  of  an 
imjocent  nature,  and  entirely  confined  to  the  antrum,  it  may  be 
removed  by  excision  of  the  superior  maxilla,  but  as  a  rule  no 
more  of  the  bone  should  be  taken  away  than  is  absolutely  neces- 
sary, the  orbital  plate  and  hard  palate  being  preserved  if  possible. 
When  the  tumor  arises  behind  the  bone,  there  is  often  great  diffi- 
culty in  getting  it  away,  as  its  attachments  may  be  more  extensive 
than  is  imagined.  If  thought  advisable  to  attempt  its  removal, 
this  may  be  done  by  excising  the  superior  maxilla,  and  clearing 
away  the  growth ;  or  the  maxilla  may  be  turned  outwards,  the 
growth  removed,  and  the  bone  replaced  i^Langenbeck's  method). 

When  the  growth  is  vialignant  and  confined  to  the  antrum,  the 
superior  maxilla  may  also  be  excised ;  but  when  it  has  invaded 
the  surrounding  parts,  it  becomes  not  only  a  question  whether  it 
can  be  completely  got  away,  but  whether  the  immunity  from  its 
return  will  not  be  of  too  short  duration  for  the  patient  to  undergo 
the  risk  of  the  operation. 

Complete  excision  of  the  upper  jaw. — Having  extracted  the 
central  incisor  tooth  on  the  diseased  side,  make  an  incision  down 
to  the  bone  in  the  direction  shown  by  the  dark  line  in  Fig.  245. 
Dissect  back  the  flap  thus  marked  out  from  the  bone,  securing 
the  larger  arteries  as  they  are  divided.  Make  .a  longitudinal  in- 
cision through  the  mucous  membrane  lining  respectively  the  floor 
of  the  nose,  and  roof  of  the  mouth  as  far  back  as  the  soft  palate, 
and  then  a  transverse  one  along  the  junction  of  the  soft  with  the 
hard  palate  on  the  diseased  side.  Now  pass  one  blade  of  the 
long  jaw-forceps  into  the  mouth  and  the  other  into  the  nose,  and 
divide  the  alveolar  process  and  hard  palate ;  cut  through  the 
nasal  process  of  the  superior  maxilla,  and  then  through  the  malar 
bone,  carrying  the  forceps  into  the  spheno-maxillary  fissure. 
Seize  the  bone  with  lion-forceps,  and  wrench  it  away  from  its  re- 
maining attachments.  The  internal  maxillary,  or  any  other  large 
artery,  should  be  tied,  and  haemorrhage  from  smaller  vessels  re- 
strained by  plugging  the  wound  with  strips  of  iodoform  gauze. 
When  the  bleeding  has  stopped,  any  growth  that  may  remain 
should  be  cut  away  or  destroyed  with  the  actual  cautery.  Unite 
the  edges  of  the  wound  with  horse-hair  sutures,  and  the  lip  with 
hare-lip  pins.  Healing  occurs  readily  and  with  little  deformity. 
An  obturator  with  false  teeth  should  subsequently  be  fitted  to  the 
mouth. 

Partial  excision  of  the  upper  jaw  usually  consists  in  leaving 
the  orbital  plate,  and  is  done  by  dividing  with  a  key-hole  saw  the 


TUMORS    OF    THE    LOWER   JAW.  539 

front  wall  of  the  antrum  along  the  margin  of  the  orbit,  and  com- 
pleting the  operation  as  above  described. 

Resection  of  the  upper  jaw  {Laiigenbeck's  operation)  consists 
in  turning  the  maxillary  bone  outwards  so  as  to  get  at  a  tumor 
behind  it,  and  then  replacing  the  bone.  As  the  connections  of 
the  bone  along  its  outer  part  are  left  intact,  its  vascular  supply  is 
not  completely  cut  off,  and  it  soon  forms  fresh  adhesions  when 
placed  back  in  position. 

Tumors  of  the  lower  jaw,  like  those  of  the  upper,  may  be 
cystic  or  solid,  innocent  or  malignant.  Cystic  ttimors,  as  in  the 
upper  jaw,  may  be  developed  in  connection  with  an  uncut  tooth 
{dentigerous  cyst),  or  around  the  fang  of  a  decayed  tooth.  They 
are  then  unilocular.  Multilocular  cystic  iiunors  have  a  marked 
predilection  for  the  lower  jaw.  They  are  probably  due  to  invasion 
of  the  jaw  by  epithelium  from  the  gum.  The  epithelial  masses 
undergo  degeneration,  leading  to  cysts  often  of  considerable  size. 
These  tumors  grow  very  slowly,  and  may  gradually  destroy  the 
whole  bone,  reducing  it  to  a  mere  shell,  but  if  completely  re- 
moved do  not  recur  locally.  They  never  affect  the  glands  or  be- 
come disseminated.  The  solid  tu7?iors  may  grow  from  the  per- 
iosteum covering  either  the  outer  or  the  buccal  aspect  of  the  jaw, 
or  from  the  interior  of  the  bone,  which  they  then  expand  around 
them.  The  osseous  tumors  usually  take  the  form  of  exostoses, 
and  are  not  uncommon  about  the  angle  of  the  jaw.  The  more 
regular  shape  of  the  lower  jaw,  its  compact  structure,  the  absence 
of  a  cavity  like  the  antrum,  its  more  isolated  condition,  and  the 
absence  of  surrounding  cavities  like  the  nose,  orbit  and  spheno- 
maxillary fossa,  make  the  diagnosis  of  tumors  in  it  more  easy. 
The  signs  are  similar  to  tumors  of  the  upper  jaw,  which  see 

(P-  536). 

Treatment. — Cystic  tumors  are  best  treated  by  free  incision  of 
a  portion  of  their  wall.  In  the  case  of  the  multilocular  cysts  the 
whole  or  part  of  the  jaw  may  be  removed.  In  excising  solid  in- 
nocent tumors  no  more  of  the  bone  should  be  sacrificed  than  is 
necessary  to  extirpate  the  disease  ;  and  such  removal,  when  pos- 
sible, should  be  done  from  within  the  mouth.  Myeloid  growths 
springing  from  the  interior  of  bone  may  often  be  enucleated,  and 
not  recur  for  many  years,  or  not  at  all.  Where  the  tumor  is 
large  and  encroaches  upon  the  ramus,  the  affected  half  of  the  jaw, 
or  if  both  halves  are  affected,  the  whole  jaw  should  be  removed 
by  disarticulation,  as  if  the  ramus  is  merely  sawn  across,  leaving 
the  coronoid  process  and  condyle,  these  are  apt  to  be  drawn  for- 
ward by  the  temporal  and  external  pterygoid  muscles  and  prove 
a  constant  source  of  annoyance.  When  the  growth  is  malignant 
or  of  large  size,  and  the  skin  and  neighboring  soft  parts  are  im- 


540 


DISEASES   OF    REGIONS. 


Fig.  245. 


plicated  and  the  glands  extensively  involved,  no  operation  as  a 
rule  is  admissible.  Cysts  developed  in  connection  with  solid 
growths  may  be  laid  open  and  the  tumor  scraped  away,  or  part  or 
the  whole  of  the  jaw,  if  the  growth  is  malignant,  may  be  removed. 
Excision  of  the  lower  jaw. — Having  ex- 
tracted the  central  or  the  lateral  incisor 
tooth,  make  an  incision  down  to  the  bone 
(in  the  way  shown  in  the  black  line  in  Fig. 
245)  through  the  lower  lip,  along  the  lower 
border  of  the  jaw,  and  thence  up  the  ramus, 
nearly  but  not  quite  to  the  lobule  of  the  ear 
to  avoid  the  facial  nerve,  tying  both  ends  of 
the  facial  artery  as  it  is  cut.  Dissect  up  the 
flap  thus  formed  from  the  bone,  and  divide 
the  bone  with  saw  and  forceps  opposite  to 
where  the  tooth  has  been  extracted.  Seize 
the  bone  with  the  lion-forceps,  drawing  it 
outwards  and  upwards,  and  divide  the  soft 
tissues  on  the  inner  surface  with  a  narrovv- 
bladed-scalpel,  keeping  close  to  the  bone  to  avoid  the  gustatory 
nerve  and  the  sub-maxillary  gland.  The  origin  of  the  genio-hyo- 
glossus  should  be  spared  if  possible,  as  otherwise  the  tongue  tends 
to  fall  backwards,  and  has  before  now  caused  suffocation.  If  this 
muscle  must  be  divided,  pull  the  tongue  forward  by  a  ligature 
through  its  tip.  Next  separate  the  internal  pterygoid,  depress 
the  jaw,  and  divide  the  temporal  muscle  at  its  insertion  into  the 
coronoid  process.  Open  the  articulation  from  the  front,  divide 
the  external  pterygoid,  and  carry  the  knife  beyond  the  condyle, 
taking  care  not  to  rotate  the  jaw  outwards  lest  the  internal 
maxillary  artery  be  stretched  round  the  neck  of  the  condyle  and 
be  thus  torn  or  divided. 


Lines  of  incision  for  re- 
moval of  upper  and 
lower  jaw. 


DISEASES  OF  THE  NOSE,  NASO-PHARYNX,  AND  ACCESSORY  CAVITIES. 

AcNE  ROSACEA  is  a  dilated  or  congested  condition  of  the  capil- 
laries of  the  nose,  usually  accompanied  in  its  later  stages  by  hyper- 
trophy of  the  sebaceous  follicles.  It  is  attributed  to  indigestion, 
exposure  to  cold,  sexual  disturbance  or  the  abuse  of  alcohol,  and 
is  most  common  in  women.  Treatment. — Remove  the  cause, 
regulate  the  diet,  and  attend  to  the  general  health.  Locally  apply 
sulphur  ointment  or  perchloride  of  mercury  lotions.  In  severe 
cases  the  dilated  vessels  may  be  incised  and  the  resulting  haem- 
orrhage restrained  by  touching  them  with  perchloride  of  iron, 
but  only  small  portions  of  the  disease  should  be  thus  treated  at  a 
time. 


BLEEDING    FROM    THE    NQSE.  54 1 

Lipoma  nasi  is  an  hypertrophy  of  the  skin,  subcutaneous  tissue, 
and  sebaceous  follicles  of  the  nose,  and  not,  as  the  name  impUes, 
an  increase  in  the  fatty  tissue.  It  is  characterized  by  the  forma- 
tion of  irregular  pendulous  lobe-like  masses,  usually  situated  on 
the  tip  and  alse  of  the  nose,  and  often  of  a  bluish-red  color.  It 
occurs  in  elderly  men,  generally  as  the  result  of  alcohohsm. 
Treatment. — The  masses  should  be  shaved  off,  care  being  taken 
not  to  cut  through  the  cartilages  into  the  nostrils,  and  the  parts 
left  to  granulate.     The  treatment  is  usually  very  successful. 

Syphilis,  rodent  ulcer,  lupus  and  epithelioma  may  all  attack 
the  exterior  of  the  nose,  but  require  no  special  description  here. 

Epistaxis  or  bleeding  from  the  nose  is  a  symptom  of  many 
and  various  conditions.  Thus — i.  In  the  young  it  often  appears 
to  occur  spontaneously  from  congestion  of  the  mucous  membrane, 
and  is  especially  common  in  girls  about  the  age  of  puberty.  2. 
In  the  plethoric  it  may  be  due  to  the  congestion  of  the  brain  or 
liver,  and  then  appears  to  give  relief  to  the  over-full  vessels.  3.  In 
the  old  or  cachetic,  on  the  contrary,  it  may  be  due  to  a  poor  or 
watery  condition  of  the  blood,  such  as  is  present  in  cirrhosis  of 
the  liver,  heart  disease,  granular  kidney,  etc.  4.  It  may  also 
occur  in  scurvy,  some  forms  of  fever,  and  in  the  hsemorrhagic  dia- 
thesis. 5.  It  is  common  after  blows  or  other  injuries  of  the  nose  ; 
and  6.  It  may  be  a  symptom  of  fracture  of  the  base  of  the  skull, 
or  of  a  fibrous  or  malignant  polypus  in  the  nose  or  naso-pharynx. 
The  symptoms  are  usually  evident.  The  blood  generally  comes 
from  one  nostril,  occasionally  from  both  ;  but  it  may  pass  through 
the  posterior  nares  and  be  swallowed,  §nd  being  afterwards 
vomited,  simulate  hsematemesis ;  or  it  may  irritate  the  larynx, 
cause  cough,  and  may  then  be  mistaken  for  haemoptysis.  On 
looking  into  the  mouth  in  such  cases,  however,  the  blood  will  be 
seen  trickling  down  the  back  of  the  throat ;  whilst  it  may  also  be 
apparent  on  examining  the  nose  with  a  speculum.  In  some  cases 
the  blood  may  be  seen  flowing  from  a  small  vessel  on  the  anterior 
and  lower  part  of  the  septum  {^seat  of  election^.  The  treatvient 
will  depend  upon  the  cause.  Spontaneous  haemorrhages  occurring 
in  the  young,  except  as  the  result  of  the  hsemorrhagic  diathesis, 
generally  stop  of  their  own  accord,  and  require  no  special  treat- 
ment beyond  those  remedies  common  in  domestic  use.  When 
due  to  congestion  and  apparently  salutary,  the  bleeding  should 
not  be  too  soon  checked.  In  cachectic  subjects  it  is  often  diffi- 
cult to  control ;  rest  on  the  back  with  the  arms  raised,  sucking 
ice,  cold  or  hot  douches,  ice  to  the  nose,  subcutaneous  injections 
of  ergotine  (grs.  iij.),  gallic  acid,  lead  and  opium  and  small  doses 
of  ergot  or  of  perchloride  of  iron,  may  then  be  tried.  Or  pellets 
of  cotton-wool  soaked  in  solutions  of  cocaine   (20/^)   may  be 


542  DISEASES    OF   REGIONS. 

placed  in  the  nostril,  or  pressure  made  on  the  upper  lip  just  be- 
low the  ala  of  the  nose,  in  order  to  compress  the  nasal  branch  of 
the  superior  coronary  artery  from  which  the  blood  is  said  often  to 
be  derived.  When  the  blood  comes  from  the  seat  of  election, 
touching  the  bleeding  point  with  the  galvano-cautery  will  at  once 
arrest  the  flow.  If  the  heemorrhage  cannot  be  controlled,  the 
posterior  nares  should  be  plugged.  The  best  means  of  effecting 
this  is  by  the  india-rubber  inflating  tampon.  This  consists  of  an 
india-rubber  tube,  with  two  dilatations  upon  it,  so  sized  and  shaped 
that  when  inflated  they  will  accurately  fill  the  posterior  and  an- 
terior nares  respectively.  It  is  passed  in  flaccid  by  means  of  a 
long  probe,  and  inflated  when  in  position  by  the  mouth  or  a  small 
syringe,  the  escape  of  air  being  prevented  by  clamping  the  tube. 
Re-inflation  is  necesaary  from  time  to  time.  The  posterior  nares 
may  also  be  plugged  by  Bellocq's  sound  (Fig.  246)  in  the  follow- 
ing manner.  A  pledget  of 
F'°-  246.  lint     or     cotton-wool     rather 

larger  than  the  aperture  to  be 
filled  (that  is,  about  half  an 
inch  by  an  inch,  or  roughly, 
the  size  of  the  last  joint  of  the 
thumb)  is  taken,  and  round 
Bellocq's  sound.  the   middle  of  this  is   tied   a 

double  piece  of  stout  thread, 
a  long  loop  being  thus  left  on  one  side,  and  two  ends  on  the 
other,  one  of  which  is  cut  off  short.  The  sound  is  then  threaded 
with  a  separate  length  of  thread,  and  passed  closed  through  the 
nostril,  and  when  the  end  has  reached  the  pharynx,  the  spring  is 
projected,  coils  round  under  the  soft  palate,  and  appears  with  the 
thread  in  the  mouth.  The  thread  is  then  seized,  pulled  forwards 
and  the  sound  withdrawn,  thus  leaving  one  end  of  the  thread 
through  the  mouth  and  the  other  through  the  nostril.  The  mouth 
end  is  now  tied  to  the  loop  of  thread  attached  to  the  pledget ; 
and  by  making  traction  on  the  thread  hanging  from  the  nose  the 
pledget,  guided  by  the  finger  in  the  mouth,  is  drawn  behind  the 
soft  palate  into  the  posterior  nares.  The  loop  of  thread  is  finally 
cut  and  tied  over  a  pledget  of  cotton-wool  or  lint,  which  is  forced 
into  the  nostril  to  form  an  anterior  plug.  Meantime  the  other 
end  of  the  thread  attached  to  the  plug  has  been  retained  hanging 
out  of  the  mouth,  and  is  now  fastened  loosely  to  the  cheek,  or  it 
may  be  allowed  to  fall  back  into  the  pharynx.  The  plugs  should 
be  kept  in  for  about  two  days.  They  are  readily  removed  by 
cutting  the  thread  over  the  anterior  plug,  and  then  withdrawing 
the  posterior  one  through  the  mouth  by  means  of  the  thread  that 
is  fastened  to  the  cheek  or  is  hanging  loose  in  the  pharynx.     A 


NASAL    CATARRH,    RHINITIS,    CORYZA.  543 

substitute  for  Bellocq's  sound,  if  this  is  not  at  hand,  may  be  found 
in  a  soft  india-rubber  or  gum-elastic  catheter,  which,  with  a  hole 
drilled  through  its  end,  can  be  used  in  a  similar  way. 

Examination  of  the  nasal  cavities. — For  the  diagnosis  of 
internal  diseases  the  nasal  cavities  should  be  illuminated  by  the 
laryngoscopic  mirror  (Fig.  264)  or  the  electric  lamp,  the  alse 
being  separated  by  some  form  of  nasal  speculum,  of  which 
Duplay's  and  Frankel's  are  the  best  (Figs.  247,  248).  'J'he 
posterior  part  of  the  nasal  cavities  can  be  explored  by  the  finger 

Fig.  247.  Fig.  248. 


Duplay's  nasal  speculum.  Frankel's  nasal  speculum. 

passed  behind  the  palate,  or  by  a  small  mirror  passed  to  the  back 
of  the  throat  {posterior  rhinoscopy).  For  detecting  necrosed 
bone  the  nasal  probe  may  be  used. 

Nasal  catarrh,  rhinitis,  coryza,  or  inflammation  of  the 
mucous  membrane  of  the  nose,  may  be  acute  or  chronic. 

Acute  cataf^rh,  coryza,  or  cold  in  the  head,  will  be  found 
treated  of  in  works  on  Medicine. 

Chronic  nasal  catai-rh  or  rhitiitis  is  most  common  in  the 
young,  especially  in  children  of  a  strumous  habit.  As  exciting 
causes  may  be  mentioned  oft-repeated  attacks  of  acute  catarrh, 
adenoid  vegetations  in  the  vault  of  the  pharynx,  nasal  stenosis, 
deflected  septum,  the  irritation  of  noxious  vapors  or  dust,  the 
abuse  of  spirits,  snuff-taking,  etc.  Several  forms,  all  of  which  are 
believed  by  some  surgeons  to  be  different  stages  of  the  same 
disease,  have  been  described.  They  will  be  classed  here  under 
the  three  heads  of  1,  the  simple;  2,  the  hypertrophic;  and  3, 
the  atrophic,  which  is  generally  attended  with  foetor.  i.  The 
simple  form  is  characterized  by  a  thin  mucous  or  muco-purulent 
discharge,  and  a  congested  appearance  of  the  mucous  membrane, 
but  is  unattended  with  any  thickening,  or  formation  of  crusts,  or 
with  foetor.  If  neglected,  it  is  apt  to  pass  into  the  next  variety. 
2.  In  the  hypertrophic  the  mucous  membrane,  especially  over  the 
turbinated  bones,  is  greatly  swollen  and  congested,  and  infiltrated 
with  inflammatory  material ;  while  the  glands  are  stimulated  to 
excessive  secretion,  and  pour  out  a  thick  yellowish-green  muco- 


544_ 


DISEASES   OF   REGIONS. 


purulent  discharge.  It  is  characterized  by  symptoms  of  nasal 
obstruction,  viz.,  stuffiness  or  blocking  of  the  nose,  nasal  tone  of 
voice,  constant  need  to  blow  the  nose,  a  vacant  expression  of 
countenance  acquired  by  keeping  the  mouth  open,  trickling  of 
the  discharge  down  the  pharynx  and  subsequent  hawking  of  it  up 
by  coughing,  and  sometimes  deafness  from  the  spread  of  inflam- 
mation to  the  Eustachian  tube.  At  times  certain  reflex  phe- 
nomena are  present,  such  as  spasmodic  cough,  asthma,  and  even 
epilepsy.  The  al?e  of  the  nose  often  appear  thickened  and  the 
inferior  turbinated  bodies  greatly  enlarged.  On  posterior 
rhinoscopic  examination  granular  pharyngitis  is  frequently  dis- 
covered, with  increase  of  the  glandular  tissue  of  the  vault  of  the 
pharynx  ;  whilst  the  hypertrophied  posterior  ends  of  the  inferior 
turbinated  bodies  may  at  times  be  seen  almost  completely  block- 
ing up  the  choanse  in  the  form  of  globular,  irregularly-furrowed 
tumors    (Figs.   249,   250).      This  variety  is  said  by  some,  but 


Fig.  249. 


Fig.  250. 


Hypertrophic     nasal     catarrh.       (St. 
Bartholomew's  Ho.spital  Museum.) 


Hypertrophy  of  the  posterior  ends  of 
the  inferior  turbinated  bodies,  with 
adenoid  vegetations  in  the  vault  of 
the  pharyn.\. 


without  sufificient  evidence  I  think,  to  pass,  after  it  has  lasted 
some  years,  into  the  third  variety.  3.  Atrophic  rhinitis,  some- 
times called  dry  ox  fmtid  catarrh,  and  by  some  ozcena,  is  appar- 
ently due  to  the  shrinking  of  inflammatory  new  formation 
infiltrating  the  tissues,  and  the  consequent  atrophy  of  the  mucous 
membrane  and  the  greater  or  less  destruction  of  the  glands.  It 
is  characterized  by  the  nasal  cavities  appearing  preternaturally 
large,  so  much  so  in  some  cases  that  the  wall  of  the  pharynx  and 
F.ustachian  tube  may  be  seen  on  looking  through  the  nostril. 
The  turbinated  bodies  appear  decreased  in  si/e,  and  the  mucous 
membrane  is  atrophied  and  j^aler  than  natural,  and  covered  with 
hard  yellowish-green   adherent  crusts.      Generally,  though   not 


CHRONIC   NASAL   CATARRH.  545 

invariably,  the  disease  is  attended  with  a  horrible  fcetor,  which  is 
usually  thought  to  be  due  to  the  decomposition  of  the  discharge 
beneath  the  crusts,  the  discharge  being  secreted  in  too  small 
quantities  and  too  thick  to  allow  of  the  throwing-off  of  the  crusts. 
By  some  the  fcetor  is  believed  to  be  due  to  the  retention  of  the 
secretions  in  some  of  the  sinuses  communicating  with  the  nose. 
In  all  forms  an  important  point  to  remember  is  that  ulceration 
does  not  occur. 

Treatment. — In  the  early  stages  much  can  be  done  in  the  way 
of  treatment,  and  by  perseverance  a  cure  may  be  obtained.  In 
the  atrophic  variety  reUef  from  the  distressing  symptom  of  foetor 
only  can  be  expected.  In  all  forms  the  general  health  must  be 
attended  to.  Thus,  in  the  strumous,  cod-liver  oil  or  maltine, 
and  the  syrup  of  the  iodide  or  phosphate  of  iron,  are  indicated. 
Locally,  in  the  simple  and  milder  forms  of  the  hypertrophic,  the 
treatment  consists  in  cleansing  the  parts  and  then  applying 
astringents  ;  the  cleansing  may  be  accomplished  by  simply  blow- 
ing the  nose,  or  if  this  is  not  sufficient,  a  cleansing  fluid  must  be 
used.  There  are  many  of  these.  The  one  I  have  found  most 
useful  is  that  known  as  Uobell's  solution,  but  peroxide  of  hydit)gen 
is  perhaps  equally  as  good.  The  cleansing  lotion  should  not  be 
used,  as  is  so  frequently  done,  by  Thudichum's  nasal  douche,  as 
by  its  means  the  deeper  recesses  and 
upper  portions  of  the  nasal  fossae  cannot  be 
reached,  and  not  only  may  much  harm  be 
done  to  the  mucous  membrane  of  the  nose, 
but  inflammation  of  the  middle  ear  may  be 
set  up.  The  solution  is  best  applied  in  the 
form  of  a  coarse  spray,  either  by  the  anter- 
ior or  posterior  nasal  spray-producer 
worked  by  double  handballs  (Fig.  251). 
When  thoroughly  cleansed,  astringent  or 
sedative   solutions — best   in    the    form    of 

sprays— should     be    applied,    and     of    these        SpraTTroducer.     a.  Nozzle 

may   be    mentioned    tannic   acid,    sulpho-       for  anterior    nares;    b. 

VI.  j'j-j  c       •  i.1.1  Nozzle  for  posterior  nares. 

carbolate  and  iodide  of  zmc  or  menthol, 

eucalyptol  (^ss.  to  .^j.),  terebene  (gr.  xx.  to  5J.),  cocaine  and 
thymol  (gr.  x.  to  .^j.},  dissolved  in  liquid  petroleum,  a  better 
vehicle  than  water  for  intra-nasal  medication.  Or  astringents  or 
iodoform  may  be  applied  in  the  form  of  powders  by  the  insuffla- 
tor, or  in  the  form  of  gelatine  bougies.  Where  there  is  great  hy- 
pertrophy, the  hypertrophied  tissues  must  be  destroyed  by  the  local 
application  of  chromic  acid,  or  the  galvano-cautery  ]  or  the  ends 
of  the  inferior  turbinated  body  if  much  enlarged  may  be  removed 
by  the  cold  wire  or  galvanic  ecraseur.  At  times  the  whole  of  the 
23* 


546  DISEASES   OF   REGIONS. 

turbinated  body  may  be  removed  with  advantage.  If  the  septum 
is  deflected,  it  must  be  straightened  ;  and  if  adenoid  growths  are 
present,  they  must  be  removed.  In  the  atrophic  form,  little  more 
can  be  done  than  cleansing  and  disinfecting  the  cavities  by 
lotions  of  carbolic  acid,  borax,  aristol  (3ss.  to  ^j.),  and  the  like; 
whilst  the  mucous  membrane  may  be  stimulated  to  secretion  by 
the  use  of  Gottstein's  nasal  tampons,  or  by  the  insufflation  of 
sanguinaria,  galanga,  etc.     Cubebs  internally  is  often  of  service. 

TuRBiNAL  ERECTION,  /.  €.,  transient  and  oft-recurring  congestion 
of  the  turbinal  bodies,  is  very  common.  The  patient  complains  of 
intermittent  attacks  of  obstruction  to  free  nasal  breathing,  espec- 
ially at  night  or  on  entering  a  hot  room,  and  of  an  attending  flow 
of  a  watery  fluid  from  the  nostrils.  On  examination  the  turbinals 
are  seen  enlarged,  but  the  enlargement  may  be  distinguished 
from  hypertrophy  by  the  turbinals  dimpling  when  touched  with  a 
probe  and  becoming  small  when  painted  with  cocaine.  Touching 
the  turbinals  in  two  or  three  places  with  the  galvano-cautery  will 
generally  effect  a  cure. 

Tuberculous  ulceration  sometimes  occurs.  It  may  lead  to 
nectosis  of  the  bone,  falling  in  of  the  nose,  and  much  deformity. 
Constitutional  remedies,  as  cod- liver  oil,  must  be  given,  and  the 
parts  cleansed  by  lotions,  application  of  iodoform,  etc.  When 
obstinate,  scraping  the  part  with  a  Volkmann's  spoon,  and  removal 
of  the  dead  bone,  is  the  treatment  indicated. 

Syphilitic  affections  of  the  nose.  In  the  early  stages  of 
syphihs,  catarrhal  inflammation  and  mucous  tubercles  are  often 
met  with,  especially  in  infants,  in  whom  they  give  rise  to  the  ob- 
structed and  noisy  respiration  popularly  known  as  snuffles.  Later, 
extensive  ulcerations,  gummata  followed  by  deep  ulcers,  necrosis 
or  caries  of  the  bones  and  cartilages,  destruction  of  the  septum 
with  falling  in  of  the  nose  and  perforation  of  the  palate,  may  occur, 
and  when  combined  with  destruction  of  the  soft  tissues  and  skin, 
are  productive  of  great  deformity.  When  a  small  portion  of  bone 
in  the  deeper  recesses  is  necrosed,  it  may  not  always  be  easy  to 
find,  but  may  be  suspected  by  the  continuance  of  a  moco-puru- 
lent  discharge  and  the  foetor  so  peculiar  to  dead  bone,  the  pres- 
ence of  foul  ulcers,  the  history  of  constitutional  signs  of  syphilis, 
and  the  absence  of  signs  of  hypertrophic  or  atrophic  catarrh. 
Often  the  bone  may  be  struck  on  examination  with  the  nasnl 
probe.  Treatment. — Iodide  of  potassium  should  be  given  in  large 
doses,  combined,  if  necessary,  with  quinine  or  bark,  and  at  times 
with  mercury.  Locally  the  parts  should  be  cleansed  and  disin- 
fected by  the  application  of  carbolic  or  other  sprays,  and  when 
dead  bone  can  be  detected  it  should  be  removed,  if  loose,  through 
the  anterior  nares  or  from  behind   the  palate  by  forceps ;  but 


P0L\Tr.  547 

sometimes  it  may  be  necessary  for  obtaining  a  sufficient  exposure 
to  resort  to  the  method  of  Rouge,  or  to  cut  through  the  upper  Up 
and  turn  aside  the  ala  of  the  nose.  In  congenital  syphihs  the 
administration  of  small  doses  of  gray  powder,  followed  by  iodide 
of  potassium  and  cod-Uver  oil,  is  productive  of  the  most  happy 
results.  In  the  ulcerative  form,  iodide  of  potassium  in  large  doses 
should  be  given. 

Lupus,  though  far  more  common  on  the  exterior  of  the  nose, 
may  sometimes  be  met  with  in  the  interior.  It  then  generally 
attacks  the  cartilage  of  the  septum,  leading  to  perforation.  It  is 
attended  with  a  foetid  discharge.  The  ulcer  is  covered  with  scabs, 
and  surrounded  with  reddish  tubercles.  Treatment. — Cod-liver 
oil,  arsenic,  and  the  complete  destruction  of  the  affected  tissue  by 
caustics,  or  by  scraping,  is  the  proper  treatment. 

Rhinoliths  or  nose  stones  may  occasionally  form  in  the  nose 
from  the  deposition  of  phosphate  of  lime  and  mucus  upon  either 
a  foreign  body  which  has  become  lodged  in  the  nose,  or  a  portion 
of  hardened  secretion.  They  give  rise  to  inflammation,  swelHng 
of  the  mucous  membrane,  and  a  foetid  discharge,  and  have  been 
mistaken  for  osteomata,  and  even  carcinomata.  When  detected 
they  should  be  removed  by  forceps,  or  if  too  large  for  this,  first 
broken  by  the  nasal  lithotrite. 

For  the  treatment  of  foreign  bodies  in  the  nose,  see  p.  349. 

Polypi. — Three  forms  are  here  described — the  gelatinous,  the 
fibrous,  and  the  malignant. 

I.  Gelatinous  or  mucous  polypi  most  frequently  spring  from  the 
mucous  membrane  covering  the  turbinal  bones,  rarely  from  the 
roof  of  the  nares,  and  scarcely  ever  from  the  septum.  They 
usually  have  a  myxomatous  structure,  that  is,  they  consist  of  deli- 
cate connective  tissue  infiltrated  with  large  quantities  of  mucin 
containing  round  and  stellate  cells,  and  are  covered  with  ciliated 
epithelium.  They  are  usually  multiple  sessile  or  pedunculated, 
and  of  an  oval,  pyriform,  or  lobulated  shape.  The  usual  symp- 
toms are  a  feehng  of  stuffiness  in  one  or  both  nostrils,  worse  in 
damp  weather,  a  nasal  tone  of  voice,  and  a  mucous  discharge. 
Certain  reflex  symptoms,  such  as  asthma,  cough,  etc.,  are  also 
occasionally  present.  On  inspection,  they  appear  as  pinkish  or 
grayish-white,  semi-translucent,  gelatinous,  movable  bodies,  soft 
and  dimpling  when  touched  with  a  probe.  When  high  up,  or  far 
back  in  the  nasal  cavities,  the  speculum  or  rhinoscope  may  be 
necessary  to  detect  them.  With  the  rhinoscope  I  have  often 
succeeded  in  detecting  a  polypus  at  the  posterior  nares  that  had 
been  previously  overlooked. 

Treatment. — They  are  best  removed  by  the  galvano-cautery,  as 
this  is  attended  with  less  pain  and  with  practically  no  hgemor- 


548  DISEASES   OF   REGIONS. 

rhage.  The  parts  should  be  previously  sprayed  with  a  20  percent, 
solution  of  cocaine,  and  after  the  removal  of  the  polypi  the  sur- 
face from  which  they  sprang  should  be  touched  with  the  galvano- 
cautery  to  prevent  a  recurrence.  If  the  cautery  is  not  at  hand, 
the  polypi  may  be  removed  by  the  cold  wire  snare  or  be  twisted  off 
by  the  ordinary  polypus  forceps.  When  they  project  into  the  naso- 
pharynx, they  may  be  removed,  either  with  the  galvano-cautery 
loop  passed  through  the  nose,  or  by  the  forceps  introduced  behind 
the  palate.  A  snuff  of  tannic  acid,  used  subsequently  to  their 
removal,  is  said  to  prevent  recurrence,  but  I  have  not  found  it  of 
much  service. 

2.  Fibrous  polypi  2iC\M2\\y  arising  from  the  interior  of  the  nasal 
cavities  are  very  rare.  Those  commonly  met  with  usually  spring 
from  the  basilar  process  of  the  occipital  bone  or  body  of  the 
sphenoid,  that  is,  from  the  roof  of  the  naso-pharynx,  and  then 
ought  properly  to  be  called  naso-pharyugeal,  as  it  is  only  after 
they  have  attained  some  size  that  they  encroach  upon  the  nasal 
cavities.  They  consist  of  fibrous  tissue  not  infrequently  mixed 
with  spindle  cells,  and  often  contain  large  thin-walled  blood-ves- 
sels, which  give  them  an  almost  cavernous  structure.  The 
mucous  membrane  covering  them  is  also  very  vascular.  They 
may  be  sessile  or  pedunculated.  As  they  increase  in  size,  they 
invade  and  displace  the  surrounding  bones,  making  their  way 
into  the  nasal  cavities,  and  into  the  pharynx,  and  projecting 
below  the  palate,  and  even  into  the  interior  of  the  skull.  They 
are  usually  met  with  in  young  adult  life.  The  symptoms  are  ob- 
struction of  one  or  both  nostrils,  a  mucous  and  often  foul-smelling 
discharge,  repeated  attacks  of  haemorrhage,  deafness,  obstruction 
to  breathing  and  sometimes  to  swallowing,  and  in  the  later  periods 
of  the  growth  the  characteristic  deformity  of  the  facial  bones 
known  as  frog-face.  They  may  be  seen  on  looking  into  the  nos- 
tril from  the  front,  or  by  the  rhinoscopic  mirror  from  the  back,  or 
maybe  felt  by  the  finger  behind  the  soft  palate.  If  not  removed, 
they  may  end  fatally  from  haemorrhage,  although  they  have  appa- 
rently a  tendency  to  undergo  atrophy  as  the  patient  gets  older. 
Treatment. — When  of  moderate  size  they  are  best  removed  by 
the  galvano-cautery,  the  wire  being  passed  through  the  nostril  and 
directed  over  the  base  of  the  growth  by  the  finger  behind  the 
palate.  The  pedicle  should  be  then  completely  destroyed  by  the 
post-nasal  electrode.  When  too  large  for  this,  an  attempt  may 
be  made  to  remove  them  by  electrolysis;  this  failing,  or  not  being 
considered  advisable,  they  must  be  exposed  by  a  preliminary  ope- 
ration. If  chiefly  confined  to  the  naso-pharynx,  the  soft  i)alate 
should  be  split,  and  the  two  halves  held  aside  by  silk  ligature, 
whilst  if  more  room  isrerpiired  part  of  the  hard  palate  may  be  cut 


OZ^NA.  549 

away  after  reflecting  the  muco-periosteum  (^Nclatori's  operation) . 
When  encroaching  chiefly  on  the  nose,  a  good  exposure  may  be 
obtained  by  dividing  the  lip  in  the  middle  line,  and  turning  it  to 
one  side  with  the  ala  of  the  nose  ;  or  if  more  room  is  required,  the 
superior  maxilla  must  be  removed.  Rouge's  operation  of  turning 
up  the  upper  Hp  and  the  cartilaginous  portion  of  the  nose  after 
division  of  the  septum,  and  the  operation  of  Langenbeck  of  turn- 
ing the  maxillary  bone  outwards  on  the  cheek,  and  then  replacing 
it  after  removal  of  the  growth,  have  their  advocates.  My  experi- 
ence of  these  last-mentioned  procedures  is  not  very  favorable. 
The  exposure  obtained  by  the  former  is  no  better  than  that  gained 
by  turning  back  the  ala ;  and  the  shock  and  haemorrhage  attend- 
ing the  latter  renders  it  very  dangerous.  Many  other  methods 
and  modifications  of  the  above  have  been  proposed,  but  for  an 
account  of  these  a  larger  work  on  Surgery  must  be  consulted. 
Having  well  exposed  the  growth  it  should  be  removed  with  the 
ecraseur  or  cutting  forceps,  or  be  scraped  off  with  a  raspatory,  and 
the  bone  destroyed  by  the  actual  or  galvano-cautery.  The  naso- 
pharynx may  then  be  plugged  with  iodoform  gauze,  the  end  of 
the  strips  being  brought  out  through  the  nose,  and  removed 
through  this  passage  after  twenty-four  hours.  At  the  end  of  the 
operation  the  palate  should  be  united,  the  lip  sutured  or  the  parts 
replaced,  according  to  which  method  of  exposure  has  been  prac- 
ticed. 

3.  Alalignant polypi. — Sarcomatous  and  cancerous  tumors  may 
arise  both  in  the  nasal  cavities  and  naso-pharynx,  and  then  con-, 
stitute  what  are  called  malignant  polypi.  They  give  rise  to  symp- 
toms similar  to  those  of  the  fibrous  polypi  already  described,  but 
their  growth  is  more  rapid,  and  they  quickly  infiltrate  surrounding 
parts  and  involve  the  neighboring  glands.  They  may  occur  both 
in  the  young  and  in  the  old.  If  a  small  piece  can  be  removed, 
the  microscope  will  reveal  its  nature.  Treatment. — When  the 
growth  can  be  got  completely  away,  early  and  free  extirpation  by 
one  of  the  methods  above  described  is  the  only  treatment. 

Oz^NA  is  a  term  which  has  been  used  very  loosely  by  authors. 
By  some  it  has  been  applied  to  all  diseases  of  the  nose  attended 
with  a  foul-smelling  discharge,  whilst  by  others  it  has  been  re- 
stricted to  the  foetid  form  of  atrophic  nasal  catarrh.  The  term, 
therefore,  as  designating  a  disease,  is  misleading,  and  should  be 
discontinued  in  this  sense.  For  purposes  of  diagnosis  it  may  be 
mentioned  that  it  is  a  prominent  symptom  in  the  following  affec- 
tions of  the  nose:  i,  atrophic  nasal  catarrh;  2,  necrosis  and 
caries,  whether  of  syphilitic  or  other  origin ;  3,  tuberculous, 
syphilitic  and  lupoid  ulceration  of  the  mucous  membrane  ;  4,  for- 
eign bodies   and    rhinoliths   in   the    nasal   cavities;  5,  purulent 


550  DISEASES   OF   REGIONS. 

catarrh  of  the  antrum  or  one  of  the  other  accessory  sinuses,  and 
6,  some  forms  of  new  growth. 

Diseases  of  the  sefium  nasi. — Blood  tumors  are  occasionally 
met  with  as  the  result  of  injury.  The  blood  is  extravasated  be- 
tween the  cartilage  and  the  soft  tissues,  generally  on  both  sides  of 
the  septum,  causing  in  both  nostrils  a  fluctuating  circumscribed 
swelling  which  may  be  readily  distinguished  from  abscess  by  its 
coming  on  immediately  after  the  injury  and  by  the  absence  of 
signs  of  inflammation.  It  should  not  be  opened,  as  the  blood 
will  become  slowly  absorbed.  It  sometimes  appears  to  be  asso- 
ciated with  fracture  of  the  septum. 

Abscesses  of  the  septum  are  not  very  common.  They  may  be 
due  to  injury  or  the  breaking  down  of  gummata,  but  occasionally 
occur  without  any  apparent  cause.  When  acute  they  may  lead  to 
perforation  of  the  septum.  The  parts  are  hot,  red  and  swollen, 
and  fluctuation  may  soon  be  detected.  A  free  and  early  incision 
should  be  made. 

Gummata  of  the  septum  occasionally  form  beneath  the  perichon- 
drium in  the  course  of  syphilis.  They  are  readily  dispersed  with 
iodide  of  potassium,  but  if  neglected  may  lead  to  necrosis  and 
perforation  of  the  septum  and  to  destruction  of  the  bones,  which 
may  sometimes  be  so  extensive  as  to  cause  falling  in  of  the  bridge 
of  the  nose. 

Deflection  of  the  septum  to  one  or  other  side  may  occur  as  the 
result  of  an  injury,  or  as  a  congenital  malformation.  It  appears  as 
a  swelling  projecting  into  and  obstructing  one  of  the  nasal  cavi- 
ties whilst  in  the  other  cavity  a  corresponding  depression  is  seen. 
The  inferior  turbinated  bone  on  the  side  of  the  concavity  is  often 
much  hypertrophied.  The  deflection  is  generally  attended  with 
some  lateral  deviation  or  even  depression  of  the  lateral  cartilages, 

Fig.  252. 


Author's  forceps  for  straightening  nasal  septum.         Retentive  apparatus  for  deflected  septum. 

and  frequently  gives  rise  to  chronic  nasal  catarrh,  and  to  many 
distressing  symptoms,  such  as  frontal  headache,  nasal  tone  of 
voice,  passage  of  mucus  into  the  pharynx,  etc.  Treatment. — 
The  septum  may  generally  be  forcibly  straightened  by  the  forceps 
shown  in  I'ig.  252,  and  then  retained  in  position  for  the  first  few 
days,  while  the  parts  are  becoming  consolidated,  by  the  retentive 
apparatus  shown   in  Fig.  253,  and  subsequently  by  ivory  or  vul- 


ADENOID    VEGETATIONS. 


551 


canite  plugs  (Fig.  254).  I  have  found  hollow  plugs  (Fig.  255) 
useful,  in  that  they  do  not  so  completely  obstruct  nasal  respiration. 
In  some  instances  portions  of  the  prominent  septum  may  be  re- 
moved by  the  nasal  saw  with  advantage.  Where  the  lateral  car- 
tilages and  nasal  bones  are  deviated  they  can  generally  be 
straightened,  even  after  many  years  have  elapsed  since  the  injury. 


Fig.  254. 


Fig.  255. 


Nasal  plugs. 


Hollow  nasal  plugs. 


Great  force,  however,  is  required,  and  care  must  be  taken,  by 
properly  padding  the  forceps,  not  to  injure  the  soft  parts.  One 
of  the  best  forms  of  retentive  apparatus  then  is,  perhaps,  the 
mask  shown  in  the  accompanying  diagram  (Fig.  256),  since  by 
its  means  a  fixed  point  is   secured  to  work  from.     As  a  mask, 


Fig.  256. 


Fig.  257. 


Author's  nasal  mask. 


Author's  fixation  cap  and  nasal  truss. 


however,  is  irksome  to  some  patients  I  have  more  recently,  for 
suitable  cases,  employed  the  nasal  cap  and  truss  depicted  in  Fig. 

257- 

Ca?-tiIaginoiis  and  osseous  tumors  of  the  septum,  though  rare, 
occasionally  occur,  and  can  be  readily  diagnosed  from  a  deflec- 
tion of  the  septum,  by  their  hard  and  resisting  nature  and  the 
absence  of  a  corresponding  depression  in  the  opposite  nostril. 
Their  removal  is  the  proper  treatment. 

Adenoid  vegetations  in  the  vault  of  the  pharynx  are  very 
common  in  childhood.     They  are  produced  by  the  hypertrophy 


552  DISEASES   OF   REGIONS. 

of  the  adenoid  tissue  which  is  so  abundant  in  this  situation,  and 
are  frequently  met  with  in  connection  with  enlargement  of  the 
tonsils,  granular  pharyngitis,  and  nasal  catarrh,  and  if  neglected 
may  set  up  catarrhal  otitis  and  incurable  deafness.  The  chief 
symptoms  to  which  they  give  rise  are  deafness,  obstruction  to 
nasal  respiration,  a  nasal  or  "dead"  tone  of  voice,  and  a  vacant 
expression  of  countenance   from  the  child   breathing  with  the 

Fig.  258. 


Author's  modification  of  Loewenberg's  forceps  for  removing  adenoid  vegetations. 

mouth  half  open.  To  the  finger,  behind  the  palate,  they  feel  soft, 
pulpy  and  velvety,  "like  a  bag  of  earthworms;"  whilst  in  the 
mirror  they  appear  as  pink  or  reddish,  sessile  or  pedunculated 
fringe-like  masses  more  or  less  obscuring  the  posterior  nares 
(Fig.  250).  The  treatment  consists  in  removing  them,  which 
may  be  done  in  several  ways.  The  softer  ones  may  be  scraped 
away  with  the  nail  of  the  finger  behind  the  palate  ;  those  about 
the  Eustachian  tubes  and  side  of  the  pharynx  are  best  extirpated 
by  Meyer's  ring-knife  (Fig.  259)   introduced  through  the  nose; 

Fig.  259. 


Meyer's  ring  knife. 

and  the  larger  ones,  which  are  situated  on  the  roof  and  back  of 
the  pharynx,  by  Loewenberg's  forceps  (Fig.  258)  passed  behind 
the  palate.  The  pharyngeal  tonsil,  which  is  usually  hypertrophied 
in  connection  with  adenoid  growths,  can  be  readily  removed  by 
these  forceps.  Ether  followed  by  chloroform  should  be  given ; 
gas  does  not  afford  sufficient  time  for  thorough  removal.  I  have 
had  to  repeat  the  operation  when  gas  had  been  employed  by 
others.  The  anaesthetic  should  not  be  pushed  beyond  "pin-point 
pupil."  Some  Surgeons  recommend  the  hanging-head  position, 
but  this  interferes  with  the  complete  removal  of  the  growths.  I 
always  myself  have  the  head  on  its  side,  so  that  the  blood  may 
run  into  the  cavity  of  the  cheek,  whence  it  can  be  readily  sponged 
away.    No  after-treatment,  beyond  compelling  the  child  to  breathe 


ETHMOIDAL   AND   SPHENOIDAL   SINUSES.  553 

through  the  nose  by  keeping  the  mouth  closed  at  night  with  a 
bandage,  is  usually  required.  I  never  employ  the  syringe,  as  I 
believe  it  is  one  of  the  chief  causes  of  the  middle-ear  trouble 
which  sometimes  occurs  after  the  removal  of  these  growths.  As 
a  precaution  against  cold  I  always  confine  the  patient  to  his  bed 
or  room  for  a  few  days. 

The  antrum  and  ihe  frontal,  ethmoidal  and  sphenoidal 
SINUSES  may  be  the  seat  of  purulent  catarrh.  The  catarrh  may  be 
due  to  simple  extension  from  the  nose  or  to  the  presence  of  nasal 
polypi,  or  the  irritation  of  a  carious  tooth  fang.  The  most  char- 
acteristic sign  is  a  unilateral  discharge  of  pale  yellow  pus.  This, 
in  the  absence  of  a  foreign  body  or  rhinolith,  necrosed  bone,  or 
syphilitic  ulceration,  is  almost  pathognomonic  of  catarrh  of  one 
of  these  sinuses.  In  catarrh  of  the  antnnn  the  discharge  is  nearly 
always  intermittent,  and  after  a  period  of  retention  is  often  foetid. 
The  pus  usually  flows  anteriorly  from  beneath  the  middle  turbinal, 
and  more  freely  when  the  head  is  depressed  or  laid  on  the  oppo- 
site side.  Some  pain  or  tenderness  may  be  elicited  by  pressing 
on  the  cheek  or  on  tapping  a  tooth,  but  often  there  is  neither  pain 
nor  tenderness.  On  percussion  there  may  be  marked  dulness, 
and  on  placing  an  electric  lamp  in  the  mouth  the  affected  cheek 
lights  up  less  brilliantly  than  the  other ;  but  an  exploratory  punc- 
ture through  the  canine  fossa,  an  empty  tooth  socket,  or  beneath 
the  inferior  turbinal,  may  be  necessary  to  settle  the  diagnosis.  In 
catarrh  of  the  other  sinuses  the  flow  of  pus  is  more  or  less  contin- 
uous, and  is  promoted  by  the  erect  position.  It  may  or  may  not 
be  foetid.  When  it  comes  from  \ht  fro?jtal  ox  an/erior  ethmoidal 
celts  it  flows  anteriorly  also  from  beneath  the  middle  turbinal ; 
when  from  the  posterior  ethmoidal  or  sphenoidal  cells,  either  pos- 
teriorly or  anteriorly,  and  then  over  the  middle  turbinal.  There 
is  usually  deep-seated  pain  at  the  back  of  the  nose  in  posterior 
ethmoidal  and  sphenoidal  trouble,  pain  in  the  orbit  and  forehead 
in  anterior  ethmoidal  and  frontal.  Exophthalmos  points  to  eth 
moidal  or  sphenoidal  mischief;  ptosis,  strabismus  and  sudden 
blindness  to  sphenoidal.  A  cautious  exploratory  puncture  through 
the  nose,  the  forehead,  or  near  the  inner  angle  of  the  orbit  will 
settle  the  question  of  pus  in  the  frontal  or  anterior  ethmoidal  cells. 
Treatment. — Sprays  such  as  those  mentioned  at  page  545  should 
first  be  used  to  subdue  the  nasal  catarrh.  If  the  discharge  still 
continues  an  attempt  may  be  made  to  wash  out  ih.t  frontal  sinus 
through  the  nares  by  the  frontal  catheter,  or,  if  this  fail,  the 
sinuses  may  be  opened  externally  by  the  trephine  and  drained. 
The  antrum  may  be  opened  and  washed  out  through  the  nares, 
the  front  wall  or  the  alveolus  of  a  tooth.  The  sphenoidal  or  eth- 
moidal sinuses  may  be  drained  by  cautiously  puncturing  through 
24 


554  DISEASES    OF    REGIONS. 

the  nose,  or  in  the  case  of  the  anterior  ethmoidal  at  the  inner 
angle  of  the  orbit. 

DISEASES    OF   THE   PHARYNX    AND    CESOPHAGUS. 

Pharyngitis,  or  inflammation  of  the  pharynx,  is  commonly  of 
the  catarrhal  variety  {acute  and  chronic pharvngitis),  but  it  may 
fall  chiefly  on  the  glands  of  the  pharynx  {foUicuhxr  or  granular 
pharyngitis) ,  or  more  rarely,  may  spread  deeply  and  end  in  sup- 
puration {phlegmonous pharyngitis) .  At  times  it  is  attended  with 
deficient  secretion  and  atrophy  of  the  mucous  membrane  {pharyn- 
gitis sicca),  and  occasionally  assumes  an  erysipelatous  character, 
and  is  then  generally  associated  with  erysipelas  of  the  face.  Here 
a  few  words  only  can  be  said  on  the  phlegmonous  form,  which, 
perhaps,  more  commonly  comes  under  the  care  of  the  general 
Surgeon.  It  is  usually  the  result  of  an  injury.  The  pharynx  is 
intensely  red  and  swollen,  the  neck  often  brawny  and  oedematous, 
swallowing  is  difficult  or  nnpossible,  respiration  is  labored,  and 
death  may  occur  in  a  few  days  from  sudden  spasm  of  the  glottis, 
or  from  exhaustion  and  blood-poisoning.  The  treatment  consists 
in  inhalations  of  steam  impregnated  with  carbolic  acid  ;  free  inci- 
sions if  pus  forms  in  accessible  situations ;  the  administration  of 
fluid  nourishment  and  stimulants,  in  the  form  of  enemata  if  the 
patient  is  unable  to  swallow  ;  and  the  performance  of  instant 
tracheotomy  if  oedematous  laryngitis  supervenes. 

Ulceration  generally  occurs  in  connection  with  like  ulceration 
of  the  palate,  fauces,  and  tonsils.  (See  Tonsils.)  Here  it  need 
only  be  said  that  the  healing  of  the  ulcers,  especially  those  of  the 
tertiary  syphilitic  variety,  is  sometimes  productive  of  great  de- 
formity. Thus,  I,  the  soft  palate  may  become  glued  to  the  back 
of  the  pharynx ;  or  2,  to  the  base  of  the  tongue  ;  and  3,  the  lower 
part  of  the  pharynx  may  be  narrowed  just  above  the  entrance  to 
the  larynx,  rendering  deglutition  difficult,  and  subjecting  the 
patient  to  the  risk  of  suffocation  from  the  lodgment  of  food  at  the 
constricted  part.  Treatment. — Adhesions  between  the  palate  and 
pharynx  can  hardly  be  remedied  ;  but  when  contraction  or  ste- 
nosis of  the  lower  pharynx  has  occurred,  the  cicatricial  bands 
should  be  divided  in  a  backward  direction  with  a  guarded  knife 
and  recontraction  ])revented  by  the  daily  passage  of  a  bougie.  I 
h.ave  found  a  Ricord's  urethrotome  answer  admirably  for  making 
the  division.  If  the  introduction  of  instruments  causes  much 
spasm,  tracheotomy  should  be  previously  i)erformed. 

Pos']  pharyngeal  AI5SCKSS  is  a  collection  of  pus  in  the  loose  cel- 
lular tissue  behind  the  pharynx,  and  is  most  often  met  with  in 
children.     It  is  generally  chronic,  and  due  to  disease  of  the  cer- 


STRICTURE   OF   THE   CESOPHAGUS.  555 

vical  vertebrae,  or  more  rarely  of  the  base  of  the  skull ;  but  it  may 
be  acute,  and  is  then  usually  the  result  of  an  injury,  as  swallowing 
acids  or  the  impaction  of  a  foreign  body,  or  of  the  exanthemata, 
phlegmonous  pharyngitis,  etc.  It  sometimes  occurs  without  ap- 
parent cause  ;  there  is  then  often  a  history  of  syphihs  or  tubercle. 
It  may  break  into  the  pharynx,  or  at  the  side  of  the  neck,  or  even 
make  its  way  into  the  mediastinum.  Symptoms. — Pain,  difficulty 
in  opening  the  mouth,  obstructed  deglutition  and  respiration,  the 
presence  of  a  fluctuating  swelling  at  the  back  of  the  throat,  and 
more  or  less  swelling  about  the  angle  of  the  jaw.  When  the  ab- 
scess is  acute,  there  is  commonly  some  febrile  disturbance.  Tirat- 
vient. — A  vertical  incision  should  be  made  in  the  middle  line 
through  the  posterior  pharyngeal  wall  with  a  properly  guarded 
knife,  the  swelling  having  been  previously  punctured  with  a  long 
grooved  needle  if  there  is  any  doubt  as  to  its  nature.  If  opened 
under  chloroform,  the  head  should  be  turned  rapidly  to  the  side 
to  allow  the  escape  of  pus  through  the  mouth,  as  suffocation  has 
occured  through  a  sudden  gush  into  the  air-passages.  When  it 
depends  upon  disease  of  the  spine,  if  an  opening  is  thought  neces- 
sary it  should  be  made  through  the  side  of  the  neck. 

Tumors  of  the  pharynx  are  rare,  though  all  varieties  may  occur. 
When  arising  in  the  loose  cellular  tissue  behind  the  pharynx,  the 
more  common  situation,  they  are  spoken  of  as  post-phai-yngeal 
tumors.  The  softer  varieties  closely  simulate  abscess,  but  the  ab- 
sence of  fluctuation  and  of  pus  on  puncture  will  settle  the  diag- 
nosis. Innocent  growths,  when  small  and  unattached  to  the  ver- 
tebrae, may  be  enucleated  through  a  vertical  incision  over  them. 
The  malignant,  as  a  rule,  should  be  left  alone. 

Pouches  of  the  cesophagus  are  occasionally  met  with.  They 
nearly  always  arise  from  the  back  of  the  tube  and  at  its  junction 
with  the  pharynx,  and  as  they  increase  in  size  bulge  in  the  neck 
on  one  or  both  sides  of.  the  cricoid  cartilage.  'Wit  symptoms  \.o 
which  they  give  rise  are  regurgitation  of  undigested  food  some 
hours  after  it  has  been  taken,  difficulty  in  swallowing,  and  later  in- 
anition. A  sound  can  at  times  be  passed  into  the  pouch  from  the 
mouth,  and  food  can  be  squeezed  out  of  the  pouch  into  the  oeso- 
phagus, the  pouch  becoming  flaccid.  The  treatment  coxi^x'sX^  m 
removing  the  pouch  through  an  incision  in  the  neck,  and  closing 
the  wound  in  the  cesophagus  with  sutures. 

Stricture  of  the  cesophagus  may  be  due  to  spasm  of  the 
muscular  fibres  {spasmodic  stricture^  to  cicatricial  contraction 
{fibrous  stricture),  or  to  epitheliomatous  or  other  malignant 
growths  of  its  walls  {malignant  stricture).  Further,  stricture  may 
be  simulated  by  compression  of  the  oesophagus  from  without  as 
by  an  aneurysm,  enlarged  thyroid  gland,  post- oesophageal  abscess, 


556 


DISEASES   OF   REGIONS. 


or  mediastinal  tumor;  or  by  a  foreign  body  impacted  in  the 
tube,  disease  at  the  back  of  the  larynx,  etc. 

Spasmodic  stricture  or  spastn  of  the  msophagus  generally  occurs 
in  young  hysterical  women.  The  patient  may  be  quite  unable  to 
swallow,  and  a  bougie,  perhaps,  will  not  pass.  The  diagnosis  will 
then  rest  on  the  obstruction  existing  only  at  times  ;  on  the  age 
and  sex  of  the  patient ;  the  presence  of  other  signs  of  hysteria ; 
but  chiefly  on  the  fact  that,  under  an  anjesthetic,  the  bougie, 
which  could  not  previously  be  passed,  slips  down  easily  into  the 
stomach.  The  treatment  should  consist  in  the  administration  of 
anti-hysterical  remedies ;  whilst  the  patient  may  be  persuaded 
that  the  bougie  has  cleared  the  passage. 

Fibrous  stricture  is  generally  due  to  cicatricial  contraction  fol- 
lowing an  injury,  as  swallowing  boiling  water  or  corrosive  fluids, 


Fibrous  strictre  of  oesophagus  at  region  of 
cricoid  cartilage.  (St.  Bartholomew's 
Hospital  Museum.) 


Malignant  stricture  of  oesophagus  at  entrance 
of  stomach.  (St.  Baitholomew's  Hos- 
pital Museum.) 


or  the  impaction  of  a  foreign  body.  More  rarely  it  results  from 
the  healing  of  a  syphilitic  ulcer.  At  times  it  appears  to  be  con- 
genital ;  at  other  times  no  cause  can  be  discovered.  It  may 
exist  at  any  part  of  the  tube,  but  is  most  common  in  the  upper 
half  (Fig.  260).  It  is  much  rarer  than  the  nialignant  form,  but 
is  liable  to  become  malignant  when  it  has  existed  for  some  time. 
As  the  result  of  the  constriction,  the  tube  above  the  stricture  be- 
comes dilated  and  the  nuiscular  coat  hypertrophied.  The  dilata- 
tion may  be  general  or  pouch-like,  in  the  latter  case  consisting 
either  of  a  dilatation  of  all  the  coats,  or  of  a  hernia  of  the  mucous 
membrane  through  the  muscular  fibres. 


STRICTURE   OF   THE    CESOPHAGUS.  557 

Ma/ignant  stricture  is  generally  epitheliomatous,  and  may  occur 
at  any  part  of  the  oesophagus,  but  is  most  common  opposite  the 
cricoid  cartilage,  at  the  bifurcation  of  the  trachea,  and  at  the 
cardiac  end  of  the  stomach  (Fig.  261),  situations  at  which  nor- 
mally slight  obstruction  to  a  bolus  of  food  larger  than  usual 
exists,  and  at  which  "developmental  processes  are  complicated, 
and  where,  therefore,  errors  of  nutrition  are  more  hkely  to  occur." 
Thus,  at  the  cardiac  orifice  the  epithelium  changes  its  character ; 
and  where  the  oesophagus  is  crossed  by  the  bronchus  the  food 
and  air-passages  were  originally  one.  Epithelioma  may  begin  as 
a  distinct  cauliflower  like  excrescence  springing  from  one  side  of 
the  tube  ;  or  as  a  nodular  induration  of  the  mucous  membrane 
involving  ring-Hke  the  whole  calibre  of  the  oesophagus.  It 
gradually  encroaches  upon  the  lumen  of  the  tube,  causing  more 
or  less  complete  obstruction.  The  growth  sooner  or  later  ulce- 
rates, and  invades  the  surrounding  tissues,  the  mediastinum, 
pleura  and  glands  ;  and  sinuses  may  form  between  the  oesophagus 
and  the  trachea  or  left  broechus,  or  open  externally  when  the 
disease  is  high  up  in  the  neck.  The  patient,  if  he  does  not  die 
of  starvation,  succumbs  to  pain  or  exhaustion,  or  to  haemorrhage 
from  the  laying  open  of  a  large  vessel,  or  to  pleurisy  or  pneumonia. 

The  symptoms,  common  to  both  the  fibrous  and  malignant 
stricture,  are — i,  increasmg  difficulty  of  swallowing,  first  of 
solids,  then  of  liquids,  and  finally  inabihty  to  swallow  either;  2,  a 
feeling  of  obstruction,  generally  referred  to  the  top  of  the  sternum  ; 
3,  regurgitation  of  food  after  it  has  been  swallowed  for  a  short 
time  (where  the  stricture  is  low  down  or  pouch-like  dilatations 
have  formed)  ;  4,  a  trickhng  sound  on  auscultation  between  the 
shoulders  whilst  the  patient  is  swallowing  fluid  ;  and  5,  progressive 
wasting  and  loss  of  strength.  The  diagnosis,  however,  can  only 
be  made  with  certainty,  and  the  situation  of  the  stricture  ascer- 
tained, by  the  passage  of  a  bougie.  But  before  attempting  to 
pass  a  bougie,  a  careful  examination  of  the  chest  should  be  made 
for  the  purpose  of  excluding  aneurysm  as  a  cause  of  the  symptoms, 
lest  such  should  be  ruptured,  as  has  before  now  happened.  The 
diagnosis  of  the  malignant  from  the  fibrous  stricture  will  rest  on 
the  advanced  age  of  the  patient,  the  absence  of  any  discoverable 
injury,  the  presence  of  blood  or  foul-smelling  discharge  on  the 
end  of  the  bougie,  a  sensation  of  passing  over  an  ulcerated  sur- 
face, and  the  presence  of  enlarged  glands  or  an  indurated  mass 
in  the  situation  of  the  tube  when  the  stricture  occurs  in  the  neck. 

Treatment. — In  the  fibrous  form  the  stricture  should  be  grad- 
ually dilated  by  bougies.  When  the  stricture  is  very  tight,  a  cat- 
gut bougie  may  sometimes  by  delicate  manipulation  be  insinuated 
through  it ;  and  over  this  a  larger  tube   may  then  be   passed. 


558 


DISEASES   OF   REGIONS. 


When  the  stricture  is  very  resiUent,  its  division  posteriorly  in  the 
middle  line  may  be  called  for  {^infernal  (xsophagotomy').  When 
the  stricture  is  situated  at  the  cardiac  end,  and  a  well-directed 
trial  at  dilatation  has  failed,  gastrostomy  may  be  performed,  and 
the  stricture  forcibly  dilated  by  the  finger  or  an  instrument  passed 
into  the  oesophagus  from  the  interior  of  the  stomach.  It  need 
hardly  be  said  that  so  serious  an  operation  should  not  be  lightly 
undertaken,  nor  until  other  means  have  failed.  In  maUgnant 
<;trictitre  dilatation  by  bougies  or  tubes,  in  the  way  recommended 
in  fibrous  stricture,  must  not  be  attempted,  as  the  walls  of  the 
oesophagus  are  so  softened  by  the  ulceration  and  disease  that  great 
danger  of  perforation  and  extravasation  into  the  mediastinum 
or  pleura  would  be  incurred.  The  methods  of  treatment  then 
open  to  us  are — i,  to  pass  an  oesophagus  tube  and  keep  it  in  situ  ; 
2,  to  perform  gastrostomy,  and  3,  when  the  stricture  occurs  in  the 
neck,  to  open  the  cesaphagus  in  the  neck,  if  possible  below  the 
seat  of  stricture,  and  stitch  the  tube  to  the  wound  in  the  skin  ;  or 
if  not  possible  to  get  below  the  stricture,  to  dilate  it  from  the 
wound.  When  a  soft  tube  can  be  passed  and  kept  /;/  si/u  this 
appears  to  be  undoubtedly  the  best  treatment.     The  tube  may 

be  introduced  through  the  mouth 
or  nose,  and  under  favorable  cir- 
cumstances will  not  need  chang- 
ing for  a  month  or  more.  Oc- 
casionally, however,  it  causes  ir- 
ritation of  the  back  of  the  tongue 
or  larynx,  or  of  the  mucous  mem- 
brane of  the  nose.  Should  this 
occur,  Mr.  Charters  Symonds'  plan 
may  be  adopted  of  passing,  by 
means  of  a  suitable  director,  a 
short  tube,  shaped  like  a  funnel  at 
one  end,  into  the  stricture,  and 
leaving  it  there  merely  attached 
by  a  strong  string,  which  is  se- 
cured to  the  cheek  or  ear  by 
strapping  (Fig.  262).  Care  must 
be  taken  that  the  patient  does 
not  swallow  the  string,  an  accident 
which  has  ha])pened  during  this 
treatment.  Excellent  results  have  followed  the  use  of  tubes ; 
patients  have  regained  flesh,  have  fairly  enjoyed  life  for  some 
months,  and  then  have  died  in  comparative  ease.  When  a  tube 
cannot  be  passed,  or  is  not  tolerated,  the  oesophagus,  if  the  dis- 
ease is  high  in  the  neck,  may  be  opened,  or  if  the  disease  is  low 
down,  gastrostomy  performed. 


A  Symonds'  tube  in  situ. 


GASTROSTOMY.  559 

Gastrostomy  is  the  operation  of  establishing  a  fistulous  opening 
into  the  stomach  for  the  purpose  of  feeding  the  patient  in  stricture 
of  the  oesophagus.  The  operation  is  now  usually  performed  in 
two  stages.  In  the  first,  the  abdomen  is  opened,  and  the  stomach 
secured  by  suture  to  the  abdominal  parietes  ;  in  the  second,  which 
is  not  performed  till  from  four  to  six  days  after  the  first,  the 
stomach,  which  by  this  time  has  become  adherent  to  the  abdo- 
minal parietes,  is  punctured,  and  a  tube  introduced,  i.  An  ob- 
lique incision  (Fig.  284,  e)  is  made  between  two  and  three  inches 
long,  about  an  inch  below,  and  parallel  with  the  left  costal  car- 
tilages, beginning  about  an  inch  and  a  half  from  the  middle  line 
(Howse).  The  sheath  of  the  rectus  is  next  opened,  the  fibres  of 
the  muscle  separated,  not  cut,  the  posterior  layer  of  the  sheath 
divided,  and  the  peritoneum  exposed.  Mr.  Howse  thinks  that 
the  fibres  of  the  rectus  subsequently  play  the  part  of  a  sphincter 
to  the  opening.  All  bleeding  having  been  stopped,  the  peritoneal 
cavity  is  opened  on  a  director,  and  the  stomach  sought  and  drawn 
into  the  wound  if  it  does  not  already  present  there.  It  may  be 
distinguished  from  the  transverse  colon  by  its  thick,  smooth  and 
pinkish-red  coat  and  the  absence  of  appendices  epiploicje.  Two 
loops  of  silk  are  passed  through  the  peritoneal  and  muscular  coat 
for  the  purpose  of  securing  a  good  hold  of  the  stomach  whilst  the 
sutures  are  being  introduced,  and  also  for  the  purpose  of  steady- 
ing it  during  the  subsequent  operation  of  opening  it,  and  thus  pre- 
venting the  risk  of  the 

adhesions  being  broken  Fig.  263. 

down.     The    stomach, 
as  near  the  cardiac  end 
as     possible,    is     now         \^       i      / 
stitched  to  the  parieties  i       |      | 

by   a  double    ring    of         lf^#      1 
sutures,  so  as  to  ensure      ,_^''i''^__ 
a   good    inch    of    the      ,^ 
stomach-wall  (that  be- 
tween   the    outer     and       / 
inner  ring  of  sutures)       %^ 

being    in     contact    with  Howse's  method  of  suture.in  gastrostomy. 

the  parietal  peritoneum 

(Fig,  263).  The  outer  ring  of  sutures  is  passed^first,  by  carrying 
the  needle,  armed  with  a  silk  suture,  through  the  serous  and  mus- 
cular coat  of  the  stomach,  and  then  through  the  abdominal 
parieties,  a  good  inch  from  the  edge  of  the  wound.  The  needle 
is  now  unthreaded  and  withdrawn,  re-threaded  with  the  stomach 
end  of  the  suture,  and  passed  through  the  abdominal  parietes,  un- 
threaded, and  finally  withdrawn.  _  When_[all  the  sutures  are  in 


560  DISEASES   OF    REGIONS. 

situ  they  are  tied  over  a  quill.  The  inner  ring  of  sutures  are  then 
passed  through  the  serous  and  muscular  coat  of  the  stomach  and 
the  skin  and  peritoneum  only  of  the  parietes,  and  tied.  The 
wound  is  dressed  antiseptically.  2.  At  the  end  of  from  four  to 
six  days  the  stomach  will  generally  be  found  adherent,  and  should 
then  be  punctured  with  a  long  sharp  tenotomy  knife,  while  it  is 
drawn  well  forwards  by  the  silk  ligatures  left  in  for  the  purpose. 
A  No.  6  or  8  English  catheter  is  passed  through  the  puncture,  and 
the  wound  again  dressed  antiseptically,  the  catheter  passing 
through  the  antiseptic  dressings.  At  first  only  teaspoonfuls  at  a 
time  of  fluid  nourishment  should  be  given;  later  a  larger  tube 
may  be  passed,  and  minced  sohd  food  introduced. 

DISEASES  OF  THE  LARYNX.  , 

Physical  examination  of  the  larynx. — For  the  diagnosis 
and  efficient  treatment  of  the  diseases  of  the  larynx  the  laryngo- 
scope is  required.  To  use  this  instrument,  place  yourself  in 
front  of  the  patient  and  the  light,  in  the  way  shown  in  Fig.  264. 
Throw  the  light  reflected  from  the  head  mirror  into  the  back  of 
the  patient's  mouth ;  draw  the  tongue,  held  by  a  towel  with  the 
left  hand,  gently  forward,  and  press  the  throat  mirror,  held  in  the 
right  hand,  firmly  but  gently  against  the  uvula  and  soft  palate. 
With  a  little  practice  an  image  of  the  larynx  is  obtained.  Ask 
the  patient  to  pronounce  the  sounds  ah,  ee,  and  the  vocal  cords 
will  come  into  view.  The  image  of  the  larynx  is  of  course  re- 
versed, the  front  appearing  in  the  throat  mirror  as  the  back.  If 
any  difficulty  is  experienced  in  obtaining  a  good  view  the  soft 
palate  and  back  of  the  mouth  should  be  sprayed  or  painted  with 
a  20  per  cent,  solution  of  cocaine.  If  any  operation  or  manipu- 
lation is  required  in  the  larynx  itself,  it  also  should  be  swabbed 
with  cocaine  by  the  laryngeal  brush. 

Laryngitis,  or  inflammation  of  the  larynx,  may  be  conveniently 
divided  into — i,  acute  catarrhal ;  2,  chronic  catarrhal ;  3,  oedema- 
tous  ;  and  4,  membraneous  laryngitis. 

Acute  cataYrhal  laryngitis  may  be  due  to  sudden  exposure  to 
cold  or  damp,  violent  exertion  of  the  voice,  or  inhalation  of 
noxious  vapors  or  impure  air  ;  or  the  inflammation  may  spread  to 
the  larynx  from  the  pharynx  ;  or  occur  in  the  course  of  other 
diseases,  as  the  eruptive  fevers.  Symptoms. —  Soreness  of  the 
throat,  hoarseness  or  even  aphonia,  laryngeal  cough,  and  tender- 
ness on  pressure  over  the  thyroid  cartilage,  accompanied  by 
febrile  sym])toms.  On  laryngoscopic  examination  the  parts  are 
seen  red  and  swollen,  and  the  cords  do  not  come  together 
properly.     l"he  treatment  consists  in  rendering  the  atmosphere 


LARYNGITIS. 


561 


moist  by  the  steam  kettle,  in  inhaling  soothing  vapors,  and  ab- 
staining from  using  the  voice  ;  whilst  if  the  attack  is  very  acute, 
leeches  or  cold  in  the  earlier  stages   may  be  appUed  over  the 


Fig.  264. 


Method  ot  using  the  1  in  ngoscope 


thyroid  cartilage.  Should  the  inflammation  assume  the  oedema- 
tous  form,  scarification,  intubation,  or  tracheotomy  may  become 
necessary  (see  CEdematous  Laryngitis^. 

Chronic  laryngitis  may  be  due  to  exposure  to  wet  and  cold, 
over-exertion  of  the  voice,  excessive  smoking,  inhalations  of  dust 
or  noxious  vapors,  syphilis,  tubercle,  and  malignant  disease.  The 
mucous  membrane  appears  thickened  and  indurated  and  covered 
with  a  muco-purulent  discharge,  whilst  the  glottis  is  narrowed 
in  consequence  of  the  thickening  of  the  mucous  membrane. 
The  syinptoms  are  cough,  hoarseness,  laryngeal  voice,  dryness  and 
irritation  of  the  throat,  and  dyspnoea,  varying  with  the  amount  of 
narrowing  of  the  glottis.  A  variety  of  chronic  laryngitis,  in  which 
the  mucous  follicles  are  chiefly  aff"ected,  is  known  as  follicular  or 
granular  laryngitis,  or  clergyman's  sore  throat,  and  is  frequently 
associated  with  a  similar  condition  of  the  pharynx.  Treatment. 
— The  application  with  the  brush  of  a  strong  solution  of  nitrate  of 


562 


DISEASES    OF    REGIONS. 


Fig.  265. 


silver  (half  a  drachm  to  the  ounce,  or  even  stronger),  absolute 
rest  of  the  voice,  residence  at  a  suitable  spa,  avoidance  of  all 
sources  of  irritation,  and  appropriate  remedies  if  there  is  any 
specific  disease. 

CEdematoiis  laryngitis  or  oedema  of  the  glottis.^ln  this  form 
there  is  an  effusion  of  serous  fluid  into  the  sub-mucous  tissue  of 
the  larynx,  especially  that  about  the  aryteno-epiglottidean  folds 
(Fig.  265).  But  the  oedema  does  not  extend  below  the  vocal 
cords,  as  the  mucous  membrane  is  tightly  attached  to  them  with- 
out the  intervention  of  any  submucous  tissue.  Cause. — It  gen- 
erally comes  on  suddenly,  and  often  supervenes  upon  some 
previous  inflammatory  condition  of  the  larynx  or  neighboring 
parts.  It  is  of  common  occurrence  after  scalds  or  burns  of  the 
throat,  stings  of  insects,  or  the  impac- 
tion in  the  larynx  of  a  foreign  body  ;  or 
it  may  occur  in  the  course  of  such  dis- 
eases as  eysipelas,  fevers,  and  small- 
pox ;  or  be  engrafted  on  tubercular  or 
syphilitic  ulceration  of  the  larynx,  peri- 
chondritis, or  necrosis  of  the  cartilage. 
CEdema  of  the  larynx  of  a  passive  char- 
acter is  also  a  frequent  termination  of 
Bright's  disease.  The  symptoms  in  the 
acuter  forms  are  most  urgent,  the 
dyspncea  is  extreme,  and  if  not  relieved 
rapidly  ends  in  spasm  and  death. 
When  less  acute  the  voice  is  affected, 
inspiration  is  often  stridulous  and 
labored,  and  swallowing  is  painful  and 
difficult — symptoms  which  may  be  fol- 
lowed by  cyanosis,  coma,  and  death. 
The  treatment  must  be  energetic ;  an 
emetic  should  be  given  at  the  onset, 
and  leeches,  ice,  or,  if  preferred,  hot 
sponges,  applied  over  the  thyroid  cartilage.  These  means  failing, 
the  cedematous  part  must  be  scarified  by  the  laryngeal  lancet,  or 
an  O'Dwyer's  tube,  if  at  hand,  ])assed  through  the  glottis,  and  re- 
tained there  until  the  oedema  subsides  ;  otherwise  laryngotomy  or 
tracheotomy  must  be  performed. 

Membraneous  larxngiiis,  laryngeal  croup  or  laryngeal  diphthei-ia, 
is  a  disease  of  childhood,  and  may  either  begin  in  the  larynx,  or 
spread  to  it  from  the  fauces  and  pharynx.  It  is  characterized  by 
the  formation  of  a  false  membrane,  which  may  extend  into  the 
trachea  and  bronchi  (Fig.  266).  The  membrane,  which  may  be 
hard   and   tough,  or  soft  and  crumbling,  and  of  a  yellowish  or 


Gidematous  Laryngitis,     i  St.  Bar- 
tholomew's Ho.spital  Museum.) 


LARYNGITIS. 


563 


grayish-white  color,  is  produced  by  the  coagulation  of  fibrinous 
material  exuded  on  the  surface  of  the  mucous  membrane.  It 
consists  of  a  delicate  network  of  fibres  enclosing  leucocytes,  cast- 
ofF  epithelium,  and  granular  debris  iu  its  meshes.  I.oeffler's  ba- 
cillus has  been  found  in  the  membrane.  On  its  separation  the 
mucous  membrane  beneath  is  generally  though  not  invariably 
found  to  be  denuded  of  epithelium,  congested  and  inflamed  ;  but 
the  mucosa  is  not  usually  involved,  as  is  the  case  in  diphtheritic 
inflammation  of  the  fauces  and  pharynx.  This  diff'erence  would 
appear  to  depend  on  the  site  of  the  inflammation  and  the  intensity 
of  the  process,  though  some  consider  it  a  point  in  favor  of  the 
non-identity  of  croup  and  diphtheria,  a  question,  however,  which 
cannot  here  be  discussed.  The  symptoms,  when  the  disease  be- 
gins in  the  larynx,  generally 
come   on  very  gradually ;   and  ^'g- 

at  first  cannot  be  distinguished 
from  an  ordinary  catarrh.  Soon, 
however,  and  often  first  during 
the  night,  the  cough  acquires  a 
ringing  or  brassy  character,  and 
soon  afterwards,  if  not  simul- 
taneously, the  inspiration  be- 
comes stridulous,  and  later  the 
voice  "hoarse,  cracked,  and 
whispering,  or  in  young  chil- 
dren totally  suppressed."  Dys- 
pnoea is  now  marked  ;  the  soft 
parts  of  the  chest-walls  recede 
during  inspiration ;  the  inspira- 
tion is  heaving ;  expiration  as 
well  as  inspiration  may  also  be- 
come impeded,  and  the  child, 
if  not  relieved,  rapidly  becomes 
cyanosed  and  dies.  When  the 
disease  spreads  from  the 
pharynx,  the  laryngeal  signs 
may  at  first  be  masked ;  but  later,  they  are  similar  to  those  given 
above.  Ti-eatment. — Internally  quinine  and  perchloride  of  iron 
may  be  given,  whilst  locally  when  any  membrane  is  visible  on  the 
fauces  and  pharynx  it  should  be  removed,  and  prevented,  if  possi- 
ble, from  re-furming  by  swabbing  out  the  throat  at  frequent  inter- 
vals with  boro-glyceride,  carbolic  acid,  or  other  disinfectant. 
The  child  may  be  placed  under  chloroform,  if  necessary,  to  en- 
sure the  thorough  removal  of  the  membrane.  Although  it  is  per- 
haps too  early  to  pronounce  an  opinion  as  to  the  exact  value  of 


Membraneous  laryngitis  or  croup  ( St. 
tholomew's  Hospital  Museum). 


564  DISEASES   OF   REGIONS. 

the  subcutaneous  injection  of  diphtheria  antitoxin,  its  efficacy 
seems  to  some  extent  to  be  undoubted,  since  a  marked  decrease 
in  the  percentage  of  mortality  from  diphtheria  has  resulted  in  the 
hospitals  where  it  has  been  used.  It  would  appear  that  the  earher 
the  injections  are  made  in  the  disease  the  more  prospect  there  is 
of  success,  since  the  antitoxin  can  only  neutralize  the  toxin  present 
in  the  system,  not  undo  the  damage  to  the  muscles  and  nerves 
already  done,  nor  control  the  secondary  septic  processes  which 
may  have  been  set  up.  The  dose  must  be  sufficiently  large,  and 
regulated  more  by  the  severity  of  the  symptoms  than  by  the  age 
of  the  patient.  The  minimum  dose  for  a  child,  according  to 
Klein,  is  3j.  to  3J^.  Washburn  and  Goodall  recommend  the 
following  doses  of  a  serum  of  which  0.000 1  c.cm.  neutralizes  a 
dose  of  diphtheria  toxm  otherwise  fatal  to  guinea-pigs  :  in  severe 
cases,  20  c.cm.  (about  gv)  when  the  patient  is  first  seen,  followed 
by  10  c.cm.  in  from  eighteen  to  twenty-four  hours,  and  again 
another  5  to  10  c.cm.  in  another  eighteen  to  twenty-four  hours, 
and  proportionately  smaller  doses  for  less  severe  cases. 

Should  the  larynx  become  obstructed,  tracheotomy  must  be 
performed.  The  chief  indications  for  this  operation  are — i, 
retrocession  of  the  soft  parts  of  the  chest-walls  ;  2,  suppression  of 
the  voice  ;  and  especially  3,  impeded  expiration.  Before  intro- 
ducing the  tracheotomy  tube  the  membrane  should  be  thoroughly 
removed  both-  from  the  trachea  and  larynx  by  a  feather  or  by  the 
suction-tube  apparatus,  and  its  re-formation  if  possible  prevented 
by  constant  spraying  of  the  part  through  the  tube  with  an  alkaline 
lotion.  The  patient's  bed  should  be  surrounded  with  curtains, 
and  the  atmosphere  kept  moist  by  steam  to  which  an  antiseptic 
is  added.  He  should  be  fed  with  soft  solid  nourishment,  and  if 
necessary  by  a  flexible  silk  tube  passed  through  the  nose.  Stim- 
ulants are  generally  required.  The  recumbent  posture  should  be 
insisted  on,  as  there  is  grave  danger,  if  the  patient  attempts  to  sit 
up,  of  sudden  and  fatal  cardiac  syncope. 

Tui'.FKCLE  OF  THE  LARYNX,  also  called  laryngeal  phthisis,  may 
sometimes  occur  as  a  primary  affection,  though  it  is  generally 
secondary  to  tubercle  of  the  lung.  It  is  characterized  by  the 
formation  of  miliary  tubercles  under  the  mucous  membrane, 
which  subsequently  break  down,  leading  to  ulceration.  The 
symptoms  are  those  of  ordinary  chronic  laryngitis,  but  in  addition 
to  these,  the  y)atient  often  presents  signs  of  pulmonary  phthisis. 
On  examination  the  mucous  membrane  looks  pale,  and  the 
aryteno-epiglottidean  folds  swollen  and  often  of  a  pyriform  shape  ; 
later,  ulceration  will  be  discovered,  and  may  be  followed  by  caries 
and  necrosis  of  the  laryngeal  cartilages,  dysphagia,  and  oedema  of 
the  glottis. — Treatment, — The  usual  constitutional  treatment  for 


SYPHILIS   OF   THE    LARYNX. 


565 


tubercular  diseases  must  be  employed.  When  ulceration  has 
occurred,  insufflation  of  morphia  and  painting  the  part  with 
cocaine  before  taking  food  may  be  tried,  to  relieve  the  cough  and 
the  difficulty  and  pain  in  swallowing.  Should  swallowing  become 
impossible,  the  patient  should  be  fed  with  the  oesophageal  tube 
whilst  lying  face  downwards.  Tracheotomy  must  be  performed 
if  suffocation  threatens. 

Syphilis  of  the  larynx. — In  the  secondary  stages  of  syphilis, 
catarrhal  inflammation,  superficial  ulceration,  and  mucous  patches 
may  occur ;  whilst  in  the  tertiary  stages  characteristic  ulcers  due 
to  breaking  down  of  gummata  are  not  very  uncommon.  Tertiary 
ulceration  may  extend  to  the  perichondrium,  or  a  gumma  may 
begin  beneath  that  membrane,  and  in  either  case  lead  to  necrosis 
or  caries  of  the  cartilages.  On  the  healing  of  the  ulcers  con- 
tractions and  adhesions  producing  stenosis  of  the  larynx  may 
ensue.  General  syphilitic  treatment,  appropriate  to  the  stage, 
should  be  employed.  Scarification  or  tracheotomy  are  called  for 
in  tertiary  affections  should  oedema  of  the  glottis  supervene.  In 
stenosis  an  attempt  may  be  made  to  dilate  the  contracted  glottis 
by  means  of  O'Dwyer's  tubes,  or  the  stricture  may  be  divided 
with  a  guarded  knife,  or  with  the  galyano-cautery. 

Tumors  both  innocent  and  malignant  occur  in  the  larynx.     Of 


Fig.  267. 


Fig.  268. 


Papilloma  of  laryn.x.     (St    P.artholomew's         Sarcoma  of  larynx.     (St.  Bartholomew's  Ho-;- 
Hospital  .Museum.)  pital  Museuin.j 


the  form.er  the  papillomata  and  fibromata  are  the  most  common, 
of  the  latter  the  epitheliomata.     The  papillomata  occur  as  warty 


566-  DISEASES   OF   REGIONS. 

or  pedunculated  excrescences,  or  as  soft,  flocculent,  villous-like 
bodies,  and  generally  grow  from  the  vocal  cords,  and  front  of  the 
larynx  (Fig:  267).  They  may  be  single  or  multiple,  llic fibro- 
7nata  are  less  common,  and  occur  as  small,  smooth,  solitary, 
spherical,  pedunculated  or  sessile  growths,  springing  from  the 
vocal  cords.  The  epithchomata  usually  grow  from  the  mucous 
membrane  covering  the  arytenoid  cartilages,  or  from  the  ventri- 
cular bands  or  cords.  A  sarcomatous  tumor  is  shown  in  the 
accompanying  illustration  (Fig.  268). 

The  chief  symptoms  of  a  growth  in  the  larynx  are  hoarseness  or 
aphonia,  and  dyspnoea.  When  the  growth  is  pedunculated  the 
symptoms  are  often  paroxysmal  and  intermittent  in  character,  in 
consequence  of  the  growth  being  moved  by  the  current  of  air  in 
respiration.  The  laryngoscope  is  essential  for  the  diagnosis. 
In  the  early  stages  it  may  be  difficult  to  distinguish  an  innocent 
from  a  malignant  tumor,  but  if  a  small  piece  can  be  removed,  a 
microscopical  examination  will  usually  clear  up  the  point.  Later, 
the  rapid  growth  of  the  tumor,  its  tendency  to  ulcerate,  its  indura- 
tion, its  involvement  of  surrounding  parts,  the  enlargement  of 
lymphatic  glands,  and  the  accompanying  pain  and  cachexiae,  will 
indicate  malignancy.  Frequently,  however,  the  lymphatic  glands 
are  not  involved,  and  there  may  be  no  cachexia. 

Treatmetit. — Innocent  growths  should  be  removed  if  possible 
by  the  intralaryngeal  method.  This  may  be  done  by  evulsion 
with  the  laryngeal  forceps,  or  by  excision  with  the  cutting  forceps, 
or  with  the  cold  wire  or  galvano-cautery  snare,  local  anaesthesia 
being  induced  by  cocaine.  When  of  very  large  size,  or  broad- 
based,  or  situated  below  the  cords,  or  in  other  parts  where  they 
cannot  be  removed  by  this  method,  laryngo-tracheotomy  or 
thyrotomy  may  have  to  be  performed.  When  a  malignant  growth 
is  confined  entirely  to  the  larynx,  and  the  glands  of  the  neck  are 
not  involved,  thyrotomy  may  still  be  performed,  and  the  growth 
completely  cut  and  scraped  away  from  the  cartilages  ;  or  if  the 
cartilages  are  found  invaded,  part,  or  even  the  whole  of  the  larynx 
may  be  extirpated.  Otherwise  palliative  treatment  only  can  be 
employed,  or  tracheotomy  performed  if  suffocation  threatens. 

OPERATIONS    ON    'JHE    AIR    PASSAGES. 

Under  this  head  are  included  tracheotomy,  laryngotomy,  lar- 
yngo-t}-acheoio?ny,  thyrotomy,  subhyoid  pharyngotomy  and  intuba- 
tion and  extirpation  of  the  larynx.  A.  'J'racheotomy,  laryngo- 
tomy,  and  laryngo-tracheotomy  may  be  required,  i,  for  establish- 
ing a  ])ermanent  opening  below  an  obstruction  of  the  larynx  ;  2, 
as  a  temporary  exi)edient  until  such  an  obstruction  can  be  re- 
moved ;  3,  for  the  extraction  of  a  foreign  body  or  growth  ;  and  4, 


OPERATIONS    ON    THE    AIR    PASSAGES. 


567 


to  prevent  blood  entering  the  trachea  during  operations  about  the 
mouth,  jaws,  tongue  and  pharynx.  B.  Thyrotomy 'and  subhyoid 
pharyngotomy  may  be  necessary  for  the  removal  of  a  growth  or 
foreign  body  when  such  cannot  be  extracted  by  the  intralaryn- 
geal  method  or  by  one  of  the  former  operations.  C.  Complete 
or  partial  extirpation  of  the  larynx  may  have  to  be  undertaken  for 
a  malignant  growth  confined  to  the  larynx.  Before  performing 
any  of  these  operations,  the  Surgeon  should  consider  well  the  an- 
atomy of  the  middle  line  of  the  neck.  Beginning  at  the  chin  is 
the  raphe  between  the  mylo-hyoid  muscles,  next  the  hyoid  bone, 
and  then  the  thyro-hyoid  membrane,  through  which  an  incision  is 
made  in  the  operation  of  subhyoid  pharyngotomy  (Fig.  269,  a). 
Below  this  is  the  pomum  Adami,  or  the  notch  in  the  thyroid  carti- 
lage, which  though  prominent  in  adults,  especially  in  males,  can 
hardly  be  felt  in  the  fat  neck  of  a  child.  An  incision  exactly  in  the 
middle  line  through  the  thyroid  cartilage  is  known  as  thyrotomy 
(Fig.  269,  b).  A  little  below 
the  thyroid  cartilage  the  cricoid  Fig.  269. 

can  be  felt.     It  is  situated  op-  ^.^--.~.. 

posite  the  fifth  or  sixth  cervical  "''"     "- 

vertebra,  and  is  an  excellent 
landmark,  as  it  can  always  be 
distinguished  however  fat  the 
neck.  Between  it  and  the  thy- 
roid cartilage  is  the  crico-thyroid 
membrane,  which  is  quite  super- 
ficial, being  covered  only  by  the 
skin,  superficial  and  deep  fascia, 
and  the  overlapping  sterno- 
hyoid muscles.  This  is  the  spot 
where  laryngotomy  is  performed 
(Fig.  269,  c).  Below  the  cricoid 
cartilage  are  two  or  three  rings 
of  the  trachea,  and  then  the 
thyroid  isthmus.  There  is  usually 
a  space  between  the  cricoid  car- 
tilage and  the  isthmus  of  a 
quarter  to  half  an  inch.  Here 
the  trachea  is  merely  covered  by  the  skin,  superficial  and  deep 
fascia,  and  the  overlapping  sterno-hyoid  muscles  on  either  side, 
and  it  is  in  this  situation  that  tracheotomy  is  best  performed  (Fig. 
269,  d).  When  the  incision  is  extended  upwards  through  the 
cricoid  as  well  as  through  the  upper  rings  of  the  trachea,  it  is 
called  taryngo- tracheotomy.  After  the  isthmus  of  the  thyroid 
gland,  which,  in  adults,  is  usually  about  half  an  inch  wide,  follow 


Situation  of  incisions  for  operations  in 
middle  line  of  neck.  a.  Subhyoid  pharyn- 
gotomy. b.  Thyrotomy.  c.  Lar^'ngo- 
tomy.  d.  Tracheotomy  above  isthmus. 
e.  Tracheotomy  below  isthmus.  The 
hnes  only  show  the  relative  situation  of 
the  incisions,  not  their  correct  length. 


568  DISEASES   OF    REGIONS. 

four  or  five  rings  of  the  trachea,  and  then  the  upper  border  of  the 
sternum.  Below  the  isthmus  the  trachea  recedes  from  the  surface, 
and  in  addition  to  the  skin  and  superficial  and  deep  fascia,  is 
covered  by  the  sterno-thyroids  as  well  as  the  sterno-hyoids,  and 
by  two  layers  of  deep  fascia  between  which  is  the  large  inferior 
thyroid  plexus  cf  veins.  Superficial  to  the  muscles,  the  anasto- 
motic branch  between  the  anterior  jugular  veins  also  crosses  the 
trachea.  On  the  trachea  itself  are  several  small  branches  from 
the  inferior  thyroid  arteries,  pnd  sometimes  the  thyroidea  ima,  an 
abnormal  branch  coming  off  from  the  aorta;  whilst,  rarely,  the 
innominate  vein  may  be  higher  than  usual,  and  cross  the  trachea 
above  the  level  of  the  sternum.  On  either  side  of  the  trachea 
low  in  the  neck  are  the  carotid  arteries.  Some  surgeons  perform 
tracheotomy  below  the  isthmus  (Fig.  269,  e)  ;  but  a  review  of 
these  anatomical  relations  makes  it  evident  how  much  greater  is 
the  risk  and  difficulty  then  attending  it. 

Tracheotomy  may  be  performed  either  above  or  below  the 
thyroid  isthmus.  The  former  situation  should,  as  a  rule,  be 
chosen,  as  here  the  operation  can  be  performed  with  greater  ease 
and  less  risk.  Moreover,  there  is  less  danger  of  suppuration  ex- 
tending between  the  layers  of  the  cervical  fascia  which  are  neces- 
sarily opened  if  the  low  operation  is  done.  In  favor  of  the  low 
operation,  on  the  other  hand,  it  is  argued  that  the  opening  is 
further  from  the  disease  when  the  larynx  is  affected,  and  nearer 
to  the  bronchi  when  a  foreign  body  has  to  be  extracted  ;  and 
that  there  is  more  room  than  above  the  isthmus,  as  the  latter 
sometimes  touches  the  cricoid  cartilage.  The  isthmus,  however, 
can  be  drawn  downwards  quite  easily  with  blunt  hooks,  or,  if 
necessary,  may  be  divided  in  the  middle  line  with  perfect  safety 
and  practically  no  haemorrhage.  If  there  be  any  advantage  in 
the  low  operation  in  that  the  treachea  is  opened  further  from  the 
disease,  it  is,  in  my  opinion,  fully  compensated  for  by  the  less  risk 
attending  the  high  operation. 

The  hi^h  operation  only  will  be  here  described.  It  may  be 
done  either  with  or  without  chloroform.  Chloroform  should,  as  a 
rule,  be  given  to  children,  as  otherwise  their  struggles  are  apt  to 
embarrass  the  operator.  In  adults,  however,  it  is  not  necessary, 
as  after  the  skin-incision  has  been  made  no  pain  is  felt,  and 
chloroform  is  liable  to  increase  the  dyspnoea,  if  present,  to  a 
dangerous  extent  and  necessitate  the  operation  being  rapidly  per- 
formed, whereas  the  more  deliberately  it  can  be  done,  the  less  are 
the  risks  attending  it.  A  small  pillow  having  been  placed  beneath 
the  neck  so  as  to  render  it  prominent,  make  an  incision  from  the 
cricoid  cartilage,  exactly  in  the  middle  line,  for  an  inch  and  a 
half  to  two  inches  downwards  according  to  the  age  of  the  patient, 


TRACHEOTOMY.  569 

fatness  of  the  neck,  etc.  (Figs.  269,  273,  d).  Divide  the  skin  and 
superficial  fascia,  and  having  found  the  interval  between  the 
sterno-hyoid  muscles  continue  your  incision  between  them,  care- 
fully avoiding  any  large  veins,  'i  he  isthmus  of  the  thyroid  will 
now  be  seen  in  the  lower  part  of  the  wound  as  a  bluish-red  body, 
and  if  sufficient  room  does  not  exist  between  it  and  the  cricoid 
cartilage,  draw  it  down  gently  with  a  blunt  hook ;  or  if  this  can- 
not be  readily  done,  notch  it  in  the  middle  Une  or  divide  it.  The 
drawing  downwards  of  the  isthmus  is  greatly  facilitated  by  divid- 
ing transversely  on  the  cricoid  the  layer  of  fascia  which  extends 
from  the  cricoid  cartilage  to  the  isthmus.  By  doing  this,  more- 
over, the  wounding  of  the  veins  between  the  layers  of  fascia  will 
be  avoided.  The  first  two  or  three  rings  of  the  trachea  having 
now  been  fully  exposed,  and  all  arterial  haemorrhage  arrested  by 
ligature  or  pressure-forceps,  thrust  the  sharp  hook  into  the  trachea 
immediately  below  the  cricoid  cartilage,  and  steadying  it  in  this 
way,  divide  the  first  two  or  three  rings  by  thrusting  in  the 
knife  with  the  back  of  the  blade  directed  downwards  and  by  cut- 
ting towards  the  cricoid.  Venous  haemorrhage,  except  from  a 
large  vein,  which,  of  course,  should  be  tied  or  clamped,  need  not 
delay  the  opening  of  the  trachea,  as  it  depends  on  engorgement 
of  the  right  side  of  the  heart,  and  will  disappear  after  two  or 
three  inspirations  through  the  tracheal  wound.  The  wound  in 
the  trachea  being  held  open  by  the  tracheal  dilator,  pass  the 
outer  tube,  made  wedge-shaped  by  pressing  it  between  the  finger 
and  thumb,  into  the  trachea,  and  then  imme- 
diately insert  the  inner  cannula,  as  until  this  ^"^-  '^^°• 
is  done,  air  cannot  freely  pass  through  the 
tube.  Secure  the  tube  /;/  situ  by  tracheotomy 
tapes  tied  behind  the  neck.  Where  the 
operation  is  performed  for  croup  or  diph- 
theria, the  tube  should  not,  as  a  rule,  be  in- 
serted at  once,  but  the  wound  held  open  by 
the  dilator,  and  any  false  membrane  removed  Parker's  cannula. 
by  a  feather  passed  both  down  into  the 
trachea  and  up  into  the  larynx,  or  if  this  does  not  succeed,  by  a 
Parker's  suction-tube  apparatus.  The  bivalve  cannula  in  general 
use  is  apt,  on  account  of  its  shape,  to  produce  ulceration  of  the 
anterior  wall  of  the  trachea,  on  which  from  its  curve  it  must  nec- 
essarily impinge ;  it  has  even  been  known  to  perforate  the  wall 
and  to  enter  the  innominate  artery.  This  can  be  prevented  by 
the  improved  shaped  cannula  invented  by  Mr.  R.  W.  Parker 
(Fig.  270).  Should  the  breathing  cease  during  the  operation,  the 
trachea  should  still  be  opened,  the  obstructing  membranes  re- 
moved, and  artificial  respiration  persevered  in  for  some  time. 
24* 


57°  DISEASES   OF   REGIONS. 

Dangers  and  difficulties  of  the  operation. — Where  the  operation 
can  be  done  deliberately,  and  on  a  patient  with  a  thin  neck,  it  is 
attended  with  no  great  difficulty ;  but  where,  as  is  frequently  the 
case,  it  has  to  be  undertaken  on  an  emergency,  possibly  with  in- 
sufficient light  and  with  no  skilled  assistant  at  hand,  or  on  a 
young  child  or  infant  with  a  fat  neck,  and  has  to  be  completed 
rapidly  to  prevent  death  from  suffocation,  it  is  perhaps  one  of  the 
most  trying  that  the  Surgeon  is  called  upon  to  perform.  'I'he 
dangers  into  which  the  inexperienced  and  unwary  may  then  fall 
are  the  following  : — 

1.  The  hyoid  bone  or  the  thyroid  cartilage  may  be  mistaken  for 
the  cricoid  cartilage,  and  the  incision  made  through  the  thyro- 
hyoid membrane  or  into  the  thyroid  cartilage.  This  mistake 
could  hardly  occur  except  in  a  fat-necked  child,  and  then  only 
through  carelessness  in  not  determining  the  position  of  the  cri- 
coid cartilage  before  beginning  the  operation. 

2.  The  interval  betiaeen  the  sterno-hyoid  muscle  may  be  missed, 
and  the  dissection  carried  to  one  or  other  side  of  the  trachea. 
The  thyroid  body  and  even  the  carotid  artery  has  in  this  way 
been  wounded.  To  avoid  such  a  disaster  the  head  should  be 
held  perfectly  straight  and  the  incision  made  "accurately  in  the 
middle  hne  ;  one  side  of  the  wound  should  not  be  retracted  more 
than  the  other ;  and  the  index  finger  should  be  used  from  time  to 
time  to  make  sure  that  the  dissection  is  being  made  over  the 
trachea. 

3.  Too  short  an  incision  may  be  made,  and  consequently  be  a 
source  of  embarrassment  in  drawing  down  the  thyroid  isthmus, 
and  in  defining  the  trachea  before  it  is  opened.  The  incision 
should  never  be  less  than  an  inch  and  a  half  long,  even  in  a  child. 

4.  One  or  more  hage  veins  may  be  wounded,  and  the  steps  of 
the  operation  be  considerably  impeded  by  haemorrhage,  'llieir 
walls  are  very  thin  ;  great  care,  therefore,  is  necessary  to  avoid 
injuring  them. 

5 .  The  knife  may  perforate  the  poste^-ior  wall  of  the  trachea  and 
enter  the  oesoi)hagus.  Caution,  therefore,  is  necessary,  and  some 
advise  that  the  knife  should  be  held,  whilst  incising  the  trachea, 
with  the  forefinger  placed  on  one  side  half  an  inch  from  its  point, 
so  that  it  cannot  penetrate  too  deeply. 

6.  The  knife  may  slip  to  one  side,  instead  of  entering  the  trachea. 
This  can  hardly  happen  if  the  trachea  is  fixed  by  the  sharp  hook 
and  drawn  well  forward  into  the  wound  whilst  being  perforated. 

7.  7'he  innotnifiate  vein  and  even  the  innominate  artery  have 
been  wounded  in  incising  the  trachea  during  the  performance  of 
the  low  operation.  The  knife,  therefore,  should  be  introduced 
with  the  back  of  the  blade  towards  the  sternum,  and  the  incision 
made  from  below  upwards. 


TRACHEOTOMY. 


571 


8.  Blood  may  enter  the  trachea,  and  if  allowed  to  remain  there 
will  coagulate,  and  the  clots  being  drawn  into  the  bronchi  and 
acting  as  plugs  may  cause  suffocation.  This  danger  should  be 
guarded  against  by  tying  all  bleeding  vessels,  and  thoroughly  ex- 
posing the  trachea  before  incising  it,  lest  there  should  be  a  vessel 
in  front  of  it.  Should  only  a  little  blood  enter  the  trachea,  it  can 
be  coughed  up  :  but  if  the  amount  is  large,  the  patient  should  be 
turned  on  his  side,  and  the  head  depressed,  the  wound  of  course 
being  held  open  by  retractors,  to  allow  it  to  run  out ;  or  if  this  does 
not  suffice,  an  attempt  must  be  made  to  remove  it  by  suction. 
When  there  is  a  general  oozing  of  blood  from  the  wound,  the  in- 
troduction of  the  tube  will  prevent  more  escaping  into  the  trachea. 

9.  The  tracheotomy  tube  may  be  forced  between  the  fascia  and 
the  front  wall  of  the  trachea;  or  one  valve  of  the  tube  may  be 
passed  inside  the  trachea,  and  the  other  outside. — To  escape  these 
accidents,  the  incision  in  the  trachea  should  be  free,  and  its 
edges  well  retracted,  or  one  edge  may  be  held  up  by  a  sharp 
hook.  To  ensure  both  valves  entering- the  trachea,  they  should 
be  pressed  well  together ;  this  may  be  conveniently  done  by 
Sankey's  forceps  (Fig.  271). 

10.  The  tube,  where  a  membrane  is  pj'esent,  may  be  passed  be- 


FlG.  271. 


Sankey's  forceps  for  introducing  tracheotomy 
tube. 


Fig.  272. 


Author's  pilot  for  Mr.  Morrant  Baker's 
soft  tube. 


tween  the  tracheal  wall  and  the  false  membrane,  a  danger  that 
may  be  guarded  against  by  removing  the  membrane  before  intro- 
ducing the  tube. 

II.  The  tube  has  been  passed  upwards  into  the  larynx  instead 
of  dowmvards  into  the  trachea. — No  excuse,  and  it  is  to  be  feared 
no  remedy,  could  be  found  for  such  gross  ignorance. 

After-treatment. — The  room  should  be  kept  at  a  uniform  tem- 
perature, the  air  rendered  moist  by  means  of  a  steam-spray  ap- 
paratus, and  the  bed  well  surrounded  with  curtains.  The  inner 
tube,  especially  if  the  operation  is  performed  for  diphtheria  or 
croup,  should  be  freed  at  frequent  intervals  with  a  feather,  or  with 
a  small  sponge  fixed  on  a  wire  ;  and  well  cleansed  by  the  nurse  at 
least  two  or  three  times  a  day.  The  outer  tube,  which  also  re- 
quires cleansing  once  a  day,  should  only  be  removed  by  the  sur- 


5  72  DISEASES    OF    REGIONS. 

geon  himself.  Where  it  is  necessary  that  a  tube  should  be  worn 
for  any  length  of  time,  Mr.  Morrant  Baker's  india-rubber  cannula 
should  be  substituted  for  a  silver  tube.  I  have  employed  this  im- 
mediately after  the  operation,  but  it  is  perhaps  safer  not  to  do  so 
until  the  wound  has  been  dilated  for  a  few  days  by  the  silver  can- 
nula, as  at  first  the  resiliency  of  the  tracheal  rings  tends  to  close 
the  wound,  and  the  india-rubber  has  been  found  in  some  in- 
stances not  sufficiently  stiff  to  resist  their  pressure.  The  pilot 
shown  in  Fig.  272,  inasmuch  as  it  renders  the  end  of  the  tube 
stiff  and  wedge-shaped,  facilitates  its  introduction.  The  india- 
rubber  tubes  may  be  worn  with  the  greatest  comfort,  and  for  pro- 
longed periods.  I  have  now  a  patient  who  has  worn  them  for 
upwards  of  five  and  a  half  years.  When  lined  with  canvas,  as 
suggested  by  Mr.  Baker,  the  tube  will  last  in  very  good  condition 
for  nearly  twelve  months.  If  a  silver  tube  be  worn  it  should  be 
examined  on  each  removal,  any  blackening  of  the  end,  and,  of 
course,  the  presence  of  blood,  being  an  indication  that  ulceration 
is  in  progress.  The  tube  should  only  be  worn  as  long  as  respira- 
tion through  the  glottis  is  impeded.  To  determine  when  the  tube 
may  be  dispensed  with  it  is  merely  necessary  to  close  the  wound 
with  the  finger  and  thus  test  the  breathing.  As  a  rule,  it  is  bet- 
ter to  remove  the  tube  at  first  only  during  the  day,  or  for  a  few 
hours  at  a  time,  or  where  a  fenestrated  cannula  is  used  the  ex- 
ternal opening  may  be  stopped  for  certain  periods  with  a  plug  to 
gradually  accustom  the  patient  to  breathe  through  the  glottis. 
When  the  tube  has  been  worn  for  any  length  of  time  some  diffi- 
culty is  often  experienced  in  leaving  it  off.  Iliis  may  depend 
chiefly  on  :  i,  the  formation  of  granulations  in  the  trachea  above 
the  opening  for  the  tube  ;  2,  adhesions  of  the  vocal  cords  to  one 
another,  and  3,  paralysis  complete  or  partial,  of  the  intrinsic  mus- 
cles of  the  larynx.  Where  granulations  are  the  cause  of  the  ob- 
struction, they  should  be  touched  at  intervals  with  nitrate  of 
silver.  Where  there  is  adhesion  of  the  vocal  cords,  the  glottis 
may  either  be  dilated  by  O'Dwyer's  tubes,  or  the  adhesions 
broken  down  by  probes  passed  up  through  the  wound  or  down 
through  the  mouth.  The  power  of  the  muscles  may  be  restored 
by  galvanism,  one  pole  being  placed  in  the  larynx,  and  the  other 
over  the  situation  of  the  recurrent  laryngeal  nerve.  In  children 
the  condition  improves  as  they  grow  older  and  as  the  larynx  be- 
comes more  developed. 

Larvn(;otomv. — Feel  for  the  cricoid  cartilage,  and  if  the  case 
is  urgent,  and  the  patient  evidently  ///  extremis,  plunge  a  pen- 
knife through  the  skin  and  subjacent  crico  thyroid  membrane 
transversely,  immediately  above  the  cricoid  cartilage,  and  hold 
the  wound  open  by  a  hair-pin,  piece  of  wire  from  a  champagne 


LARYNGO-TRACHEOTOINIY.  5  73 

bottle,  etc.  When  the  operation  can  be  done  deliberately,  make 
an  incision  exactly  in  the  middle  line  cf  the  neck  from  a  little 
above  the  lower  border  of  the  thyroid  cartilage  to  a  little  below 
the  upper  border  of  the  cricoid  cartilage  (Figs.  269  and  273,  c), 
and  the  crico-thyroid  membrane  having  been  thus  exposed,  incise 
it  transversely,  introducing  the  knife  immediately  above  the  cri- 
coid cartilage,  so  as  to  be  as  far  as  possible  from  the  vocal  cords, 
and  in  order  to  avoid  wounding  the  little  crico-thyroid  artery 
which  anastomoses  with  its  fellow  usually  across  the  upper  part 
of  the  space.  This  artery,  though  commonly  so  insignificant  that 
any  haemorrhage  from  it  could  be  readily  controlled  by  the  tube, 
is  sometimes  of  considerable  size,  and,  if  then  wounded,  would 
require  tying.  The  laryngotomy  tube  should  be  somewhat  com- 
pressed from  above  downwards,  so  as  better  to  correspond  with 
the  shape  of  the  crico-thyroid  space.  Some  surgeons  recommend 
that  the  incision  through  the  crico-thyroid  membrane  should  be 
vertical,  as  the  anterior  jugular  veins  and  the  crico-thyroid  mus- 
cles have  been  injured  in  making  the  transverse  incision,  and  an 
aerial  fistula  has  at  times  remained  after  the  latter  has  been  em- 
ployed. Further  the  vertical  incision  has  this  advantage,  that  it 
can  be  prolonged  downward  through  the  cricoid  cartilage  if  more 
room  is  required. 

Laryngo-tracheotomy  consists  in  prolonging  the  incision  in 
the  trachea  through  the  cricoid  cartilage.  It  is  sometimes  done 
when  there  is  not  room  between  the  cricoid  cartilage  and  the 
isthmus  for  the  performance  of  tracheotomy  ;  also  for  the  purpose 
of  removing  a  growth  from  the  larynx.  Although  no  harm  may 
follow  the  division  of  the  cricoid,  it  should  be  avoided,  if  possible,  as 
the  integrity  of  the  larynx  is  thereby  interfered  with,  and  serious 
impairment  of  the  vocal  apparatus  has  occasionally  been  the  result. 

Comparison  of  the  operations  of  tracheotomy  and  laryngotomy. 
Laryngotomy  is  a  much  easier  operation  and  can  be  done  with 
greater  rapidity  than  tracheotomy.  For  this  reason  it  is  par  ex- 
cellence the  one  to  be  undertaken  on  an  emergency,  as,  for 
instance,  threatened  suffocation  from  the  impaction  of  a  portion 
of  food  at  the  entrance  of  the  larynx.  In  children  tracheotomy, 
or,  in  the  case  of  an  emergency,  laryngo-tracheotomy,  should  al- 
ways be  undertaken,  as  the  crico-thyroid  space  in  them  is  too 
small  to  admit  a  tube.  In  adults,  when  either  laryngotomy  or 
tracheotomy  can  be  performed  deliberately,  the  opinions  of  Sur- 
geons are  somewhat  at  variance  as  to  which  operation  ought  to 
be  undertaken  for  the  varying  conditions  calling  for  an  opening 
into  the  air-passages  below  the  glottis.  For  my  own  part  I  always 
do  tracheotomy  (except  in  cases  of  emergency),  as  this  operation 
does  not  interfere  with  the  integrity  of  the  larynx ;  whereas  after 


574  DISEASKS    OF    REGIONS. 

laryngotomy  the  voice  has  at  times  been  lost  or  impaired  owing 
to  contraction  of  the  crico-thyroid  membrane,  or  to  inflammation 
of  the  crico-thyroid  joint  or  crico-arytenoid  joint.  Further,  there 
is  often  difficulty  with  the  tube.  This  opinion,  however,  is  not 
held  by  all.  Thus,  according  to  Mr.  Erichsen,  laryngotomy 
should  be  performed  in:  i.  Acute  cederaatous  laryngitis.  2. 
Membraneous  laryngitis  in  adults.  3.  Chronic  syphilitic  and 
ulcerative  laryngitis.  4.  Tumors  and  foreign  bodies  obstructing 
the  larynx.  5.  Scalds  and  injuries  of  the  larynx  by  acids.  6. 
Accidents  during  operations  about  the  head  and  face  in  which 
blood  accumulates  in  the  larynx;  and  7.  Laryngeal  spasm  and 


Incisions  in  certain  operations  on  the  neck.  a.  Subhyoid  pharyngotomy.  b.  Thyrotomy. 
c.  Laryngotomy.  d.  Tracheotomy  above,  anil  r  below,  the  isthmus  of  thyroid.  /.  Liga- 
ture of  subclavian  (3rd  part),  g.  Ligature  of  lingual,  k.  Ligature  of  temporal,  t.  Liga- 
ture of  common  carotid. 

paralysis  from  compression  of  the  recurrent  nerve.  Tracheotomy, 
on  the  other  hand,  he  advises  to  be  done  for:  i.  Membraneous 
laryngitis  in  children ;  2.  Foreign  bodies  in  the  trachea  or 
bronchi;  3.  Impaction  of  foreign  substances  in  the  larynx;  4. 
Necrosis  of  the  cartilages  with  obstructive  thickening  of  the 
tissues;  and  5.  As  a  preliminary  to  certain  operations  attended 
with  haemorrhage  about  the  face  or  mouth. 

Thvro'iomv,  or  laying  open  the  larynx  from  the  front  by  divid- 
ing the  thyroid  cartilage  in  the  middle  line,  may  be  required  for 
the  removal  of  a  tumor  or  a  foreign  body  impacted  in  the  larynx, 
after  a  thorough  and  carfeful  attempt  has  been  made  to  extract  it 


,    LARYNGECTOMY    OR    EXTIRPATION    OF   THE    LAR\'NX,  575 

by  the  natural  passages  {^intralaryngeal  method).  Make  an  in- 
cision accurately  in  the  middle  line  of  the  neck  from  the  hyoid 
bone  to  the  cricoid  cartilage  (Figs.  269  and  273,  b),  and,  having 
exposed  the  thyroid  cartilage,  and  stopped  all  bleeding,  divide  it 
along  the  angle  formed  by  the  junction  of  the  alae,  taking  care  to 
do  so  in  the  middle  line  so  as  not  to  injure  the  vocal  cords. 
Separate  the  alee,  and  remove  the  growth,  etc.,  and  bring  the  alse 
accurately  together  again,  and  unite  them  by  silver  wire  or 
kangaroo-tail-tendon  sutures,  which  should  not,  however,  be 
passed  through  the  whole  thickness  of  the  cardlage.  When  the 
removal  of  the  growth  is  Ukely  to  be  attended  with  haemorrhage, 
tracheotomy  should  first  be  performed  and-  the  trachea  plugged 
by  Hahn's  cannula.  The  head  should  be  kept  low  and  on  one 
side  after  the  operation,  and  the  tube  removed  if  possible  at  once 
or  within  twenty-four  hours. 

Subhyoid  pharyngotojvh.'  consists  in  opening  the  pharynx 
through  the  thyro-hyoid  membrane  (Figs.  269  and  273,  a),  for 
the  purpose  of  removing  a  tumor  or  impacted  foreign  body  at  the 
entrance,  or  in  the  upper  part  of  the  larynx.  It  is  so  rarely  re- 
quired that  the  steps  of  the  operation  are  not  given  in  detail. 

Initjbation  of  THE  LARYNX  consists  in  passing  a  properly- 
shaped  tube  through  the  glottis  by  means  of  a  forceps  or  pilot 
invented  for  the  purpose.  The  tubes  now  used  are  those  known 
as  O'Dwyer's.  Intubation  is  employed  as  a  substitute  for  laryn- 
gotomy  or  tracheotomy  in  certain  cases,  as  oedematous  laryngitis, 
membraneous  laryngitis,  etc.  It  does  not  seem  likely  that  intuba- 
tion, as  has  been  maintained  by  some,  will  replace  tracheotomy 
for  membraneous  laryngitis,  since  there  is  a  danger  of  the  mem- 
branes being  forced  into  the  trachea  by  the  tube,  thus  causing 
obstruction,  nor  does  the  intubation  admit  of  the  removal  of  the 
membranes  as  can  be  done  after  tracheotomy.  In  cedematous 
laryngitis,  however,  it  is  a  very  useful  procedure. 

Laryngectomy  or  extirpation  of  the  laryntc. — Partial  or 
complete  removal  of  the  cartilages  of  the  larynx  may  be  required 
for  malignant  disease  when  the  growth  is  confined  to  that  organ 
and  the  glands  in  the  neck  are  not  involved.  First  perform 
tracheotomy,  and  plug  the  trachea  with  Hahn's  tampon  cannula, 
and  continue  the  administration  of  the  anaesthetic  through  it. 
Next  make  an  incision  in  the  middle  line  of  the  neck  from  the 
hyoid  bone  to  the  tracheotomy  wound  ;  free  the  upper  part  of  the 
trachea  and  the  larynx  from  their  attachments  by  dissecting  close 
to  these  structures,  securing  all  bleeding  vessels  as  they  are 
divided.  Divide  the  trachea  above  the  cannula  and  detach  the 
larynx  from  the  remaining  connections,  working  from  below  up- 
wards.    Where  part  of  the  larynx  can  be  saved,  the  risks  of  the 


576  DISEASES   OF   REGIONS. 

operation  will  be  greatly  lessened.  Lightly  plug  the  wound  with 
antiseptic  gauze,  leaving  the  cannula  ///  situ  for  twenty-four  hours. 
The  patient  should  lie  with  his  head  low  and  on  one  side  and 
should  be  fed  at  first  through  a  soft  tube  passed  down  the  oesoph- 
agus, and  by  nutrient  enemata.  On  the  healing  of  the  wound  an 
ardficial  larynx,  if  the  whole  organ  has  been  removed,  may  be 
fitted  to  the  parts,  by  the  help  of  which  the  patient  will  be  able  to 
speak  moderately  distinctly. 

DISEASES    OF     IHE    PAROTID    GLAND. 

Parotitis  or  mumps,  is  an  acute  infectious  disease  attended 
with  sharp  febrile  disturbance,  and  with  a  local  inflammation  of  the 
parotid  gland.  There  is  generally  much  pain  and  swelling,  but 
neither  redness  nor  tendency  to  suppuration.  On  the  subsidence 
of  the  inflammation  in  the  one  gland,  the  opposite,  if  not  already 
affected,  generally  becomes  inflamed,  or  more  rarely  the  testicle, 
ovary,  or  mamma  is  attacked — a  condition  spoken  of  as  metastasis. 
Confinement  to  the  house,  a  gentle  laxative,  and  a  belladonna  or 
opiate  liniment  or  poppy  fomentations  to  soothe  the  pain  is  all 
that  is  usually  required. 

Parotitis  may  follow  surgical  operations,  especially  those  involv- 
ing the  abdominal  cavity.  It  soon  subsides  if  the  original  wound 
runs  an  aseptic  course,  but  if  it  be  due  to  septic  absorption  sup- 
puration quickly  ensues  (pysemia). 

Parotid  abscesses  should  be  opened  by  an  incision  in  front  of 
the  posterior  border  of  the  jaw  to  avoid  the  external  carotid 
artery,  and  parallel  to  the  facial  nerve. 

Parotid  tumors  may  begin  in  the  parotid  gland  itself,  or,  as 
is  perhaps  more  often  the  case,  in  one  of  the  lymphatic  glands 
situated  over  it.  They  have  a  great  tendency  to  displace  or  de- 
stroy the  parotid,  and  to  extend  deeply  amongst  the  important 
structures  behind  the  ramus  of  the  jaw,  where  they  may  surround 
the  carotid  arteries,  or  even  encroach  upon  the  pharynx.  In 
structure  they  may  be  fibrous,  myxomatous,  cartilaginous,  sarco- 
matous or  carcinomatous.  The  tumor,  however,  most  common  in 
the  parotid  region  consists  of  cartilage  intermixed  with  fibrous 
tissue,  with  atrophied  glandular  elements,  and  often  with  mucous 
tissue.  The  cartilage  which  so  frequently  exists  in  parotid  tumors 
is  believed  to  be  derived  from  the  elements  of  the  rudimentary 
fcetal  structure  concerned  in  the  development  of  the  lower  jaw, 
and  known  as  Meckel's  cartilag<;.  Cysts  are  very  rare,  but  cystic 
degeneration  of  the  solid  tumors  is  not  infrequent. 

Symptoms  and  diai^ndsis. — The  differential  diagnosis  of  the 
various  parotid  tumors  cannot  be  here  attempted.  Nor  is  it  of 
consequence,  as  it  is  often  impossible  before  removal  to  determine 


BRONCHOCELE    GOITRE.  577 

their  exact  nature.  The  practical  points  for  the  Surgeon  to  con- 
sider are: — Is  the  growth  innocent  or  mahgnant?  Can  it  be 
safely  removed?  Iiiiiocefit  tumors  grow  slowly,  and  are  at  first 
freely  movable,  smooth  or  slightly  lobulated,  circumscribed,  hard 
and  firm  or  semi- elastic ;  but  as  they  increase  in  size  they  may 
become  soft  or  fluctuating  in  places,  either  from  mucoid  softening 
or  cystic  degeneration.  The  skin  over  them,  though  stretched 
and  thinned,  is  non-adherent,  and  the  glands  are  not  affected. 
Malignant  tumors,  on  the  other  hand,  grow  rapidly,  are  ill-defined 
in  outHne,  generally  soft  or  semi-fluctuating,  and  become  firmly 
fixed  to  the  surrounding  parts ;  the  skin  is  adherent,  purplish-red, 
brawny,  infiltrated  with  the  growth,  and  later  ulcerated ;  and  the 
lymphatic  glands  are  enlarged.  An  innocent  tumor,  however, 
after  having  grown  slowly  for  many  years  may  suddenly  take  on 
rapid  growth  and  malignant  characters. 

Treatment. — When  the  tumor  appears  innocent,  of  moderate 
size,  and  freely  movable,  indicating  that  its  attachments  are  not 
deep,  there  can  be  no  question  about  its  excision.  But  when  of 
very  large  size,  especially  if  firmly  fixed  to  surrounding  parts,  or  if 
malignant,  unless  quite  small  and  the  skin  and  glands  are  not  to 
any  extent  involved,  it  should  be  left  alone.  The  Operatio?i. — 
Make  a  free  longitudinal  incision  through  the  skin  and  fascia  to 
thoroughly  expose  the  tumor ;  it  will  then  often  readily  shell  out 
of  its  capsule  ;  if  not  draw  it  forward  with  vulsellum  forceps,  and 
separate  its  deeper  attachments  v/ith  the  handle  of  the  scalpel 
and  occasional  touches  of  the  knife,  the  edge  of  which  should  be 
turned  towards  the  tumor  to  avoid  the  branches  of  the  facial 
nerve  and  other  important  structures.  The  proximity  of  the 
carotids  should  not  be  forgotten. 

DISEASES    OF   THE    THYROID    GLAND. 

Bronchocele  goitre  or  DERBYSHIRE  NECK  is  an  enlargement  of 
the  thyroid  gland.  It  may  be  due,  as  is  commonly  the  case,  to 
simple  hypertrophy  of  the  normal  tissues  of  the  organ  {ordi?iary 
goitre),  and  may  then  involve  the  whole  gland  or  one  of  the 
lateral  lobes,  or  rarely  only  the  isthmus.  In  other  instances  the 
hypertrophy  may  fall  chiefly  on  the  fibrous  tissue  constituting  the 
septa  of  the  gland  {fibrous  goitre).  Or  along  with  some  amount 
of  simple  hypertrophy  and  increase  of  fibrous  tissue  {adenoma), 
one  or  more  of  the  normal  alveolar  spaces  may  become  enlarged, 
forming  single  or  multiple  cysts  {cystic goitre).  Such  cysts  con- 
tain when  single  a  serous  fluid,  or  when  multiple  a  colloid  or  a 
dark  grumous  material  sometimes  mixed  with  altered  blood  ; 
whilst  occasionally  proliferating  growths  project  into  their  interior 
from  the  cyst-walls.     In  other  instances  again,  but  more  rarely, 

25 


578  DISEASES   OF   REGIONS. 

the  hypertrophy  is  associated  with  a  great  increase  in  the  vessels, 
and  a  forcible  and  expansile  pulsation  is  given  to  the  gland 
.  {puhaiing  goitre) .  But  the  tissues,  besides  hypertrophy,  may 
undergo  secondary  changes.  Thus  calcification  may  occur,  and 
the  enlarged  gland  become  in  places  of  stony  hardness  {calcified 
goitre),  or  the  fluid  normally  contained  in  the  alveolar  cavities 
may  assume  a  colloid  character.  Lastly,  the  enlargement  of  the 
thyroid  may  be  due  to  malignant  disease  {malignant  goitre). 
Goitre  in  certain  districts  is  endemic,  especially  in  the  Rhone 
Valley  in  Switzerland,  and  in  Derbyshire,  and  is  then  frequently 
associated  with  the  condition  known  as  cretinism.  It  also  occurs 
sporadically ;  and  in  some  cases  again  is  accompanied  by  a 
peculiar  jerking  beat  in  the  carotids,  by  ansemia,  and  by  a  prom- 
inence of  the  eyeballs  {exophthalmic  goitre),  for  a  full  account  of 
which  a  work  on  Medicine  must  be  consulted. 

The  Symptoms  common  to  any  form  of  enlargement  of  the 
thyroid  is  a  swelling  taking  more  or  less  the  characteristic  shape 
of  the  thyroid  gland,  and  moving  with  the  larynx  in  deglutition. 
In  this  country  the  enlargement  is  generally  moderate ;  but 
sometimes,  and  especially  in  Switzerland,  the  goitre  forms  a  large 
mass  hanging  down  in  front  of  the  neck,  and  may  press  upon  or 
even  displace  the  trachea  and  oesophagus.  It  occurs  chiefly  in 
women.  In  the  ordinary  variety  it  feels  soft,  semi-fluctuating, 
and  of  uniform  consistency ;  in  the  cystic,  one  or  more  fluctuat- 
ing places  may  be  felt ;  whilst  in  the  fibrous  it  will  be  firm  and 
hard  and  more  or  less  lobed  or  irregular,  and  where  calcification 
has  taken  place  of  stony  hardness.  Malignant  goitre,  which  is 
very  rare,  may  be  known  by  rapid  growth,  enlarged  glands,  and 
the  other  signs  of  malignancy  mentioned  at  page  79. 

The  Cause  of  endemic  goitre  is  not  known.  It  has  been 
attributed  to  impure  water,  water  from  limestone,  and  snow  water, 
but  without  conclusive  evidence.  It  is  said  to  be  most  prevalent 
in  valleys  where  from  their  direction  the  sun  does  not  penetrate, 
on  damp  soil,  and  in  damp  parts  of  towns,  but  according  to  Mr. 
Berry  these  influences  have  little  or  nothing  to  do  with  its  causa- 
tion. In  sporadic  cases,  heredity,  disturbance  of  the  sexual 
functions,  and  conditions  producing  congestion  of  the  head  and 
neck,  are  given  as  causes. 

Treatment. — Sporadic  cases  of  ordinary  goitre  should  be 
treated  by  the  internal  and  external  application  of  iodine.  Thus 
the  syrup  of  the  iodide  of  iron  may  be  given  internally  and  an 
ointment  of  iodine  and  iodide  of  potassium  applied  externally. 
The  use  of  biniodide  of  mercury  ointment,  followed  by  exposure 
to  a  hot  sun,  has  been  attended  with  much  success  in  India.  An 
ice  collar  has  sometimes  been  of  service.     Injection  of  iodine  or 


BRONCHOCELE   GOITRE.  579 

of  perchloride  of  iron  into  the  solid  parts  of  the  growth  is  highly 
dangerous,  sudden  death  having  occurred  either  from  the  acci- 
dental entrance  of  air  or  injection  of  the  iron  or  iodine  into  a 
vein.  In  cystic  goihr  the  cyst  can  as  a  rule  be  readily  shelled  out 
from  the  rest  of  the  gland.  Where  great  dyspnoea  has  threatened 
suffocation,  the  whole  gland  has  been  removed  ;  but  since  it  has 
been  shown  that  such  removal  is  productive  of  myxoedema  or  a 
condition  like  it  (^stnimapriva),  it  is  a  question  whether  com- 
plete removal  is  ever  justifiable.  It  is  better  to  divide  the  isthmus 
in  the  middle  line  for  the  purpose  of  freeing  the  trachea  (which 
is  compressed  laterally,  not  from  before  backwards)  or  to  remove 
the  isthmus  or  one  lobe  of  the  gland,  when  the  rest  will  generally 
shrink.  If  necessary  to  remove  both  lateral  lobes  the  lower  end 
of  each  should  be  left,  namely  that  part  into  which  the  inferior 
thyroid  artery  enters.  The  recurrent  nerves  are  not  then  en- 
dangered {Mikulicz's  operation).  In  removing  either  lateral 
lobe  of  the  gland  it  should  be  borne  in  mind  that,  although  the 
common  carotid  artery  is  pushed  outwards,  the  internal  jugular 
vein  usually  runs  over  the  tumor,  being  held  more  or  less  in 
position  by  the  veins  opening  into  it.  The  pulsation  of  the  artery 
is,  therefore,  no  guide  to  the  position  of  the  vein,  which  may  run 
in  front  of,  or  internal  to  the  artery.  Care  should  also  be  taken 
not  to  open  the  thin  capsule  of  fascia  surrounding  the  gland 
either  in  front  or  at  the  outer  side  in  order  to  avoid  wounding  the 
large  and  thin-walled  veins  which  lie  beneath  it.  Behind,  where 
this  capsule  is  reflected  on  to  the  larynx  and  trachea,  it  must 
necessarily  be  divided.  At  this  spot  the  veins  should  be  tied. 
Endemic  goitre  admits  of  little  treatment  other  than  removal  of 
the  patient  from  the  goitrous  district.  Malignant  goitre  except 
when  it  involves  only  a  portion  of  the  gland  is  not  amenable  to 
treatment.  The  propriety  of  partial  extirpation  of  the  thyroid 
for  exophthalmic  goitre  is  still  an  open  question.  For  the  general 
treatment  of  this  disease  a  work  on  Medicine  must  be  consulted. 
Acute  goitre. — Goitre,  though  usually  chronic,  sometimes  oc- 
curs in  an  acute  fv.rm,  the  gland  increasing  to  the  size  of  an 
orange  in  a  few  days,  and  causing  severe,  or  it  may  be  fatal, 
dyspnoea,  from  presiuie  on  the  trachea,  in  consequence  of  the  en- 
largement taking  place  so  rapidly  that  the  fascia  of  the  neck  has 
not  time  to  yielit.  It  occurs  in  young  subjects  both  sporadically 
and  endemically.  In  these  instances  it  sometimes  makes  its  way 
behind  the  sternum,  so  that  it  is  difficult  to  get  below  it,  even  if 
tracheotomy  is  performed.  The  cause  of  the  dyspnoea  may  not 
be  very  evident  before  the  operation.  Treatme^it. — The  pressure 
may  sometimes  be  removed  by  simply  incising  the  fascia  of  the 
neck.     Or  tracheotomy  may  be   done,  and  a  long  tube  passed 


S8o 


DISEASES   OF   REGIONS. 


down  the  trachea  beyond  the  obstruction  •  or  the  isthmus,  or  one 
lobe,  may  be  excised.  The  patient,  in  the  meanwhile,  should  be 
removed  from  the  goitrous  district. 

DISEASES   OF    THE   SPINE. 

Scoliosis  or  lateral  curvature  is  a  complicated  distortion 
in  which  the  spine  forms  two  or  more  lateral  curves  with  their 
convexities  in  opposite  directions,  whilst  the  vertebrae  involved  in 
the  curves  are  rotated  on  their  vertical  axes  so  that  the  spinous 
processes  are  directed  towards  the  concavity  of  the  curves. 

Cause. — The  immediate  cause  that  underlies  the  formation  of 
lateral  curvature  is  the  unequal  compression  of  the  mto-vertebral 
cartilages  for  long  periods.  This  unequal  compression  may  be 
induced  by  i,  any  condition  causing  permanent  or  habitual  ob- 
liquity of  the  pelvis  and  the  consequent  throwing  of  the  spine 
over  to  the  opposite  side  ;  such  as  unequal  length  of  the  legs, 
knock-knee,  flat-foot,  the  use  of  a  wooden  leg,  habit  of  standing 
on  one  leg,  sitting  cross-legged,  congenital  dislocation  of  the  hip, 
etc.  ;  2,  a  one-sided  position  of  the 
F'ti-274-  body  in  sitting,  standing,  or  lying,  or 

produced  by  certain  employments,  as 
nursing  or  carrying  with  one  arm,  etc. ; 
3,  contraction  of  one  side  of  the  chest 
following  empyema  ;  4,  unilateral  con- 
traction of  the  spinal  muscles  following 
paralysis  of  the  opposing  muscles. 
The  conditions  mentioned  under  i  and 
2  are,  however,  by  far  the  most  fre- 
quent causes  of  the  deformity.  Al- 
though lateral  curvature  may  be  in- 
duced by  these  causes  acting  alone, 
there  are  certain  circumstances  that 
appear  es])ecially  to  predispose  to  the 
deformity,  by  producing  a  general  want 
of  tone  in  the  muscles,  and  structural 
weakness  of  the  ligaments  and  bones. 
Such  are,  1 ,  heredity  :  2,  general  de- 
bility;  3,  the  strumous  diathesis;  4, 
rickets ;  and  5,  rapid  growth.  It  is 
much  more  frequently  met  with  in  girls 
than  in  boys,  and  is  most  common  from 
about  the  age  of  fourteen  to  eighteen. 
J\it}tology. — The  long-continued  un- 
equal compression  of  the  intervertebral  cartilages  causes  them  to 
become  wedge-shaped,  and  the  portion  of  the  spine  correspond- 


Latcral  curvature  of  the  spine. 
(St.  Bartholomew's  Hospital 
Museum.) 


SCOLIOSIS   OR   LATERAL   CURVATURE. 


581 


ing  to  the  compressed  cartilages  to  assume  sooner  or  later  a 
permanent  lateral  curve.  Whilst,  however,  a  curve  is  thus  being 
produced,  say,  in  the  dorsal  region  with  its  convexity  to  the  right, 
a  compensating  curve  in  order  to  maintain  the  equilibrium  of  the 
spine  is  being  simultaneously  produced  in  the  lumbar  region  with 
its  convexity  to  the  left  (Fig.  274).  Coincidently  with  these 
changes  a  rotary  movement  of  the  aifected  vertebrae  upon  their 
vertical  axes  is  taking  place,  so  that  while  the  bodies  turn  towards 
the  convexity  of  the  curve  the  apices  of  the  spinous  processes 
turn  towards  the  concavity.  Hence,  in  addition  to  the  formation 
of  the  primary  and  the  secondary  or  compensating  curves,  we 
have  a  twisting  round  of  the  spine  within  these  curves,  as  a  con- 
_sequence  of  which  the  ribs  on  the  convex  side  are  carried  back- 
wards with  the  transverse  processes,  causing  the  angle  of  the 
scapula  on  that  side  to  project ;  whilst  the  ribs  on  the  concave 
side  are  for  the  same  reason  carried  forwards,  producing  a  prom- 
inence of  the  corresponding  breast  (Fig.  275).  The  cause  of 
the  rotation  has  been  variously  explained.  The  theory,  perhaps, 
most  generally  accepted  is  that  of  Dr.  Judson,  who  beheves  that 
the  rotation  is  due  to  the  fact  that  the  posterior  portion  of  the 
vertebral  column,  being  a  part  of  the  dorsal  parietes  of  the  chest 
and  abdomen,  is  confined  by  the  ligaments  and  muscles  to  the 
median  plane  of  the  trunk  ;  whilst  the  anterior  portion,  projecting 
into  the  thoracic  and  abdominal  cavities,  being  devoid  of  lateral 
attachments,  is  free  to  move  either  to  the  right  or  left  of  the 
median  plane  when  the  spine  is  inclined  to  either  side.  i\t  first 
the  bones  are  not  af- 
fected, but  when  the  Fig.  275. 
compression  of  the  car- 
tilages has  become  per- 
manent the  bodies  of  the 
vertebrse  also  gradually 
assume  a  wedge  shape, 
whilst  the  articular  pro- 
cesses become  con- 
tracted and  flattened  on 
the  concave  side  and 
elongated  on  the  convex. 
The  ligaments  and  mus- 
cles on  the  concave  side  are  shortened  and  atrophied,  whilst  on 
the  convex  side  the  ligaments  are  stretched  and  the  muscles  be- 
come hypertrophied. 

Signs. — Pain  or  a  feeling  of  weakness  in  the  back,  general  lassi- 
tude, and  a  stooping  gait,  are  amongst  the  early  symptoms  ;  but 
the  patient  is  generally  first  brought  for  consultation  on  account 


To  show  the  effect  of  rotation  in  lateral  curvature  of 
the  spine. 


582  DISEASES   OF   REGIONS. 

of  a  slight  projection  of  the  scapula,  or  an  apparent  prominence 
of  the  ihac  crest — a  growing  out  of  the  shoulder  or  of  the  hip,  as 
it  is  popularly  termed.  In  slight  cases  there  may  be  little  or  no 
lateral  deviation  of  the  apices  of  the  spinous  processes,  and  the 
little  there  is  may  be  made  to  disappear  on  suspending  the 
patient  or  placing  her  in  the  prone  position.  In  the  severer 
cases,  however,  the  signs  are  unmistakable.  Thus,  in  the  more 
common  forms,  there  is  usually  a  dorsal  curv^e  with  its  convexity 
to  the  right,  and  a  shorter  lumbar,  or  dorso-lumbar  curve,  with  its 
convexity  to  the  left.  The  right  shoulder  is  generally  elevated, 
and  the  angle  of  the  right  scapula,  right  iliac  crest  and  left  breast 
are  prominent,  whilst  the  left  lumb  r  muscles,  in  consequence  of 
the  backward  projection  of  the  left  lumbar  transverse  processes, 
stand  out  as  a  prominent  ridge  and  give  a  greater  sense  of  re- 
sistance on  pressing  over  them  than  normal.  In  other  cases  the 
compensating  curves  may  be  so  slight  that  there  is  apparently  a 
single  curve  only,  with  its  convexity  either  to  the  right  or  left,  in- 
volving the  whole  spine  or  chiefly  the  upper  dorsal  or  the  lumbar 
vertebrae,  and  producing  more  or  less  projection  of  the  scapula 
or  apparent  prominence  of  the  iliac  crest,  etc.,  according  to  its 
severity  and  situation. 

Treatment. — Where  there  is  evidence  of  general  or  muscular 
debility,  the  health  and  muscular  tone  should  be  improved  by 
suitable  remedies,  the  avoidance  of  late  hours,  fatigue  and  the 
like  ;  whilst  the  exciting  cause  of  the  curvature  should  be  looked 
for  and  if  possible  removed.  In  slight  cases,  the  above  means, 
when  conjoined  with  a  judicious  selection  of  muscular  exercises 
and  partial  recumbency,  will  generally  serve  to  cure  or  improve 
the  curvature,  or  at  least  prevent  it  from  gettirg  worse.  But  in 
severe  cases,  when  osseous  changes  are  already  confirmed,  some 
form  of  rigid  support,  as  a  poro-plastic  jacket,  or  a  light  spinal 
instrument,  will  commonly  be  required,  Cbpeci  I'y  for  the  poorer 
classes  of  patients.  In  ordering  such  supp-jrts,  however,  the 
patient  should  be  made  to  thoroughly  understand  that  no  real 
improvement  of  the  curvature  must  be  expected  from  them,  their 
only  aim  being  to  relieve  pain  when  ]jresent,  to  give  a  sense  of 
comfort  and  support,  to  nn])rove  the  outward  api)earance,  and  to 
prevent  further  deformity.  In  slight  cases  they  should  on  no  ac- 
count be  used.  The  exercises  that  I  employ  are  directed  in  part 
to  improving  the  muscular  tone  generally,  and  in  part  to  strength- 
ening those  muscles  in  particular  that  tend  to  lessen  or  straighten 
the  curves.  For  the  former  purpose,  such  exercises  as  swinging 
by  the  hands  from  a  bar,  forcibly  stretching  an  elastic  cord  fixed 
to  the  floor,  and  dumb-bell  exercises,  should  be  practised.  For 
strengthening  the  muscles  in  particular  that  tend  to  straighten  the 


KYPHOSIS.  5  83 

curve,  the  back  should  be  manipulated  till  that  posture  is  found 
in  which  the  curves  are  least  marked,  and  the  patient  made  to 
hold  herself  in  this  position  for  as  long  as  possible.  At  first  she 
will  be  only  able  to  do  this  for  a  few  minutes  at  a  time ;  but  by 
frequently  assuming  the  posture,  the  muscles  thus  brought  into 
play  are  gradually  strengthened,  till  at  last  the  improved  posture 
is  maintained  constantly  and  without  effort.  For  further  improv- 
ing the  tone  of  these  muscles,  Professor  Busch  and  Mr.  Roth 
recommend  some  such  exercises  as  the  following  : — The  patient's 
body  held  in  the  improved  posture  is  brought  over  the  end  of  a 
couch  or  table,  and  whilst  she  is  prevented  from  falling  by  an  as- 
sistant holding  her  legs,  she  alternately  flexes  and  extends  her 
body  at  the  hips,  the  surgeon  resisting  her  efforts.  I  have  also  ' 
found  the  use  of  the  sloping  seat,  as  recommended  by  M.  Bouvier 
and  Mr.  Barwell,  of  considerable  service  in  counteracting  the 
curves.  A  similar  effect  may  be  obtained  by  wearing  a  thick  sole 
on  one  boot,  and  by  sitting  on  the  off-side  of  the  horse  when 
riding.  After  the  exercises,  or  tv/ice  or  thrice  during  the  day,  the 
patient  should  he  on  her  back  for  half  an  hour  to  an  hour,  and 
whilst  sitting  her  back  should  be  supported  by  a  rechning  chair, 
I  have  had  very  considerable  success  in  removing  rigidity  in 
cases  where  there  is  slight  osseous  deformity  by  applying  a  weight 
to  the  convexity  of  the  curve,  the  patient  standing  with  her  legs 
straight  and  body  horizontal  and  supported  in  this  position  by 
her  elbows  on  a  chair. 

Kyphosis  is  a  general  curving  of  the  spine  with  its  convexity 
backwards,  or  an  exaggerated  condition  of  the  normal  dorsal 
curve.  It  depends  upon  an  unequal  compression  of  the  inter- 
vertebral cartilages  and  to  a  less  extent  of  the  vertebral  bodies, 
which  thus  become  wedge-shaped  with  their 
bases  looking  posteriorly.     It  is  generally  the  ^ig.  276. 

result  of  muscular  debility,  rickets,  slouching 
habits,  or  occupations  necessitating  stooping. 
The  point  of  chief  interest  is  to  distinguish  it 
from  the  serious  angular  curvature  induced  by 
caries.  In  children,  and  in  adults,  this  is  gen- 
erally easy  ;  but  in  rickety  infants,  in  whom  the 
ordinary  tests  for  caries  (see  p.  586)  cannot  be 
applied,  it  is  often  very  difficult.  In  such  a 
case,  the  infant  should  be  laid  across  the  nurse's 
knees  and  gently  extended,  when  the  rickety 
curve  will  disappear,  but  the  angular  will  remain.  Author's  spinal  brace. 
The  back,  moreover,  in  caries,  is  rigid,  and  the 
child  is  uneasy  in  this  position  and  tries  to  resist  the  extension  by 
muscular  effort,  and  draws  up  his  legs.     In  rickets  the  back  is 


584  DISE.\SES   OF   REGIONS. 

flexible  and  there  are  other  signs  of  rickets.  Treatment. — In  the 
infant,  recumbency ;  in  growing  lads  and  girls  the  correction  of 
stooping  habits  by  the  use  of  muscular  exercises  and  a  spinal  brace 
(Fig.  276),  with  partial  recumbency,  and  tonics,  is  the  treatment 
usually  indicated.  For  the  confirmed  kyphosis  of  the  old,  noth- 
ing can  be  done. 

Lordosis,  or  curving  of  the  spine  with  the  convexity  forwards, 
is  a  symptom  rather  than  a  disease,  inasmuch  as  it  is  formed  as 
a  compensatory  curve  to  restore  the  equilibrium  of  the  spine 
when  from  any  cause  its  normal  anteroposterior  curves  are  dis- 
turbed. Thus  it  is  most  common  in  the  lumbar  region,  where  it 
is  merely  an  exaggeration  of  the  normal  curve  ;  and  is  there  pro- 
duced to  counterbalance  the  tilting  forward  of  the  pelvis  conse- 
quent upon  hip-disease,  congenital  dislocation  of  the  hips,  rickets, 
etc. 

Caries  of  the  spjne,  also  called  Pott's  disease  after  the  surgeon 
who  fiist  accurately  described  it,  is  characterized  by  the  destruc- 
tion of  one  or  moie  of  the  bodies  of  the  vertebras  or  intervertebral 
cartilages,  and  in  consequence  of  this  destruction  is  too  frequently 
attended  by  the  falling  forward  of  the  vertebrae  above  the  seat  of 
disease,  and  the  production  of  angular  deformity  of  the  spine. 
Hence  it  is  often  spoken  of  as  angular-  ciiwature.  The  curve, 
however,  is  only  a  symptom,  and  a  comparatively  late  one,  of  the 
disease,  and  ought  not  to  be  allowed  to  form. 

Causes. — The  disease  generally  occurs  in  strumous  children, 
and  is  then  believed,  like  fungating  caries  in  the  articular  ends 
of  bone,  to  be  due  either  to  a  low  form  of  inflammation  set  up  by 
a  slight  injury,  or  to  a  deposit  of  tubercle  dependent 'upon  the 
introduction  of  tubercle  bacilli  into  the  circulation  in  the  manner 
already  mentioned  in  the  section  on  Di/wnk.  It  sometimes  oc- 
curs in  adults  who  are  otherwise  perfectly  healthy,  and  can  then 
generally  be  traced  to  some  injury  of  the  back — probably  a  strain 
of  the  intervertebral  cartilages. 

Pathology. —  The  disease  most  frequently  begins  in  the  bodies 
of  the  vertebrae,  less  frequently  in  the  intervertebral  cartilages ; 
but  in  either  case  both  structures  soon  become  involved.  In  the 
bodies  it  generally  starts  as  a  rarefying  osteitis  in  the  actively- 
growing  la)  er  of  bone  which  exists  under  the  epiphysial  carti- 
lages and  periosteum.  The  inflammatory  changes  that  ensue  are 
similar  to  those  already  described  in  rarefying  osteitis  of  can- 
cellous bone.  The  red  gelatinous  inflammatory  material  or  gran- 
ulation-tissue invarlcs  both  the  l)ody  of  the  vertebra  and  the  inter- 
vertebral cartilages,  and  may  then  attack  the  vertebrae  above  and 
below.  Not  infre(|uently  several  of  the  vertebras  are  affected  in- 
dependently by  the  disease  at  the  same  time.     In  this  granula- 


CARIES    OF   THE    SPINE.  585 

tion-tissue  non-vascular  areas,  presenting  the  appearance  of  the 
tubercle  nodules  already  described,  have  been  found,  and  tuber- 
cle bacilli  have  in  some  cases  been  demonstrated  in  them.  At 
this  stage  the  disease  may  cease,  the  granulation  tissue  become 
converted  into  bone,  and  no  angular  deformity  result.  More 
commonly,  however,  the  granulation- tissue,  having  destroyed  the 
bone-trabeculae,  undergoes  caseation,  and  breaks  down  into  pus, 
producing  a  spinal  abscess;  or  it  may  be  absorbed  without  the 
formation  of  any  pus  {dij  caries)  ;  or  if  the  process  has  been  very 
acute,  large  portions  of  the  cancellous  tissue  may  die  en  masse, 
forming  sequestra,  which  may  keep  up  the  morbid  process  for 
years  {caries  necrotica).  In  any  of  these  cases  angular  deformity 
will  be  the  result,  as  partly  by  its  own  weight,  and  partly  by  the 
dragging  of  the  abdominal  muscles,  the  upper  portion  of  the 
spine  thus  undermined  falls  forward,  and  nec- 
essarily forms  an  angle  with  the  lower  portion  Fig.  277. 
at  the  seat  of  the  disease.  In  consequence  of  m — J^T^ 
the  patient's  efforts  to  hold  himself  upright  the  '  T  oi 
normal  lumbar  and  cervical  curves,  when  the 
disease  occurs  in  the  dorsal  region,  will  be 
greatly  increased ;  the  angular  projection  is 
thus  thrown  backwards  (Fig.  277),  and  the 
well-known  hump-back  produced.  When  the 
disease  occurs  in  the  lower  lumbar  region  there 
is  no  means  of  restoring  the  balance,  and  the 
patient  is  compelled  to  stand  or  walk  with  the 
body  incHning  forwards,  and,  in  severe  cases, 
nearly  at  right  angle  with  the  pelvis.  When 
the  disease  begins  in  the  intervertebral  fibro- 
cartilages,  it  probably  starts  as  a  low  form  of 
destructive  inflammation    consequent  upon  a     Caries  of  the  spine  (St. 

T_i   .     1  ,•  ii.  ■     •  r   iU  i.-  Bartholomew's  Hos- 

slight  laceration  or  other  irjuiy  01  the  cnrti-  pitai  Museum.) 
lage.  But  however  it  begins,  it  soon  involves 
the  adjacent  bones,  destroying  them  along  with  the  cartilage  and 
leading  to  the  angular  deformity.  The  spinal  cand,  situated  as 
it  is  in  the  posterior  segment  of  the  column,  with  the  exception 
of  being  bent,  undergoes  but  little  alteration  of  its  calibre,  and 
the  cord,  as  the  bending  of  the  canal  occurs  but  slowly,  conse- 
quently usually  escapes  injury.  When  the  disease  is  acute  and 
the  bending  consequently  more  rapid,  some  amount  of  temporary 
paralysis  may  occur,  impairment  or  los-  of  motion  being  far  more 
frequent  than  loss  of  sensation,  on  account  of  the  proximity  of 
the  anterior  motor  columns  to  the  diseased  vertebral  bodies. 
The  cord  is  occasionally  pressed  upon  by  portions  of  bone  sep- 
arated from  the  vertebrse,  or  by  pus  making  its  way  into  the  canal, 


586  DISEASES   OF   REGIONS. 

or  by  inflammaton'  thickening  of  the  membranes  {pachymenin- 
gitis). It  may  sometimes  undergo  softening,  leading  to  perma- 
nent paraplegia. 

Spinal  abscess  {psoas  ajid  lu??ibar). — When  suppuration  oc- 
curs, the  pus  collects  in  front  of  the  diseased  vetebrse  in  the 
angle  formed  by  the  falling  forward  of  the  upper  upon  the  lower 
portion  of  the  spine.  The  anterior  common  ligament  and  perios- 
teum, relaxed  by  the  bending  of  the  spine,  yield  to  the  pressure 
of  the  pus,  and  with  the  pleura  or  peritoneum  become  thickened 
and  form  the  abscess  wall.  The  pus,  prevented  from  travelling 
upwards  by  the  overhanging  vertebrae,  downwards  in  front  of  the 
column  by  the  attachments  of  the  anterior  common  ligament,  and 
backwards  by  the  posterior  common  ligament  and  by  the  ver- 
tebrae being  less  diseased  behind  than  in  front,  makes  its  way  on 
one  or  other  side  of  the  column.  There  it  either  enters  the 
sheath  of  the  psoas,  and  destroying  the  contained  muscle,  pre- 
sents in  the  iliac  fossa  or  groin  as  an  ihac  or  a  psoas  abscess,  or 
passes  backwards  through  or  external  to  the  quadratus  lumborum, 
and  points  in  the  loin,  where  it  is  known  as  a  lumbar  abscess.  In 
rare  instances  the  pus  may  take  a  different  course.  Thus  I  have 
seen  it  make  its  way  into  the  ischio-rectal  fossa,  or  pass  through  the 
great  sciatic  foramen,  or  travel  along  the  course  of  a  rib  and  reach 
the  surface  near  the  sternum.  Occasionally  an  abscess  forms  on 
both  sides  of  the  spine  at  once.  In  the  cervical  region  the  abscess 
will  point  in  the  ])harynx  {posi-pharytii^eal abscess) ,  or  m  the  neck. 

Process  of  cure. — Under  favorable  circumstances  the  granula- 
lation-tissue  undergoes  ossification  without  the  production  of  any 
deformity  ;  but  after  the  deformity  has  taken  j^lace,  and  the  ver- 
tebrce  above  and  below  the  disease  have  come  into  contact  by  the 
falling  forward  of  the  upper  portion  of  the  spine,  the  destructive 
process,  if  the  parts  are  kept  at  rest,  may  cease  ;  and  firm  osseous 
ankylosis,  but  with  a  permanent  angular  curvature,  will  ensue. 

Symptoms. — In  the  early  stages,  before  the  angular  deformity 
is  produced,  pain  is  felt  on  percussion  over  the  diseased  vertebra, 
or  better  on  the  head  of  the  rib  in  connection  with  it,  or  on 
gently  pressing  on  the  shoulders,  or  tapping  on  the  head,  or  on 
applying  hot  sponges  to  the  spine.  Pain  also  is  felt  in  the  course 
of  the  intercostal  nerves  and  hence  in  the  case  of  the  lower  in- 
tercostals  may  be  referred  to  the  abdomen.  It  is  increased  on 
movement ;  hence  the  spine  is  held  stiffly  by  the  muscles.  The 
movements  of  the  child  are  characteristic.  If  asked  to  pick  up 
anything  he  does  not  bend  his  back,  but  placing  his  hand  upon 
his  knee  to  support  his  spine,  reaches  the  ground  by  bending  his 
legs  and  holding  his  back  straight.  If  asked  to  turn  around  he 
rotates  the  whole  body,  not  the  back.     He  walks  about  supporting 


CARIES    OF   THE    SPINE.  587 

his  spine  by  resting  his  hand  on  the  various  portions  of  furni- 
ture, and  soon  gets  tired  of  play,  and  is  noticed  to  lie  about  on 
the  floor.  In  older  patients  tingUng  or  numbness  may  be  com- 
plained of  in  the  extremities,  and  a  feeling  as  if  a  cord  were  tied 
tightly  round  the  body.  Later,  a  prominence  of  one  or  more 
vertebrae  occurs,  and  the  nature  of  the  disease  can  no  longer  be 
doubted.  If  neglected,  the  prominence  increases,  and  the  well- 
known  angular  deformity  is  produced.  Now,  especially  if  the 
disease  is  high  up  the  spine,  some  loss  of  motion  in  the  lower  ex- 
tremities occurs,  and  may  progress  to  complete  paralysis  of  mo- 
tion. Sensation  is  not  usually  affected,  as  the  posterior  columns, 
being  remote  from  the  disease,  escape.  Nor  are  the  bladder  and 
rectum  usually  implicated.  If  an  abscess  has  not  already  formed, 
and  especially  if  the  disease  is  moderately  low  down,  one  may 
now  present  in  the  loin  {h/mbar  abscess),  in  the  iliac  fossa  {iliac 
abscess),  or  in  the  groin  {psoas  abscess).  The  first  gives  rise  to 
a  fluctuating  tumor  between  the  last  rib  and  the  crest  of  the 
ilium  just  external  to  the  erector  spinse  ;  the  second  to  a  swelling 
in  the  iliac  fossa.  The  psoas  abscess  may  be  known  by  the  swell- 
ing being  at  first  external  to  the  femoral  vessels,  by  the  impulse 
on  cough,  and  by  fluctuation  being  detected  on  pressing  above 
and  below  Poupart's  ligament.  The  abscess  makes  its  way  under 
the  femoral  vessels,  and  then  generally  points  at  the  inner  and 
upper  part  of  the  thigh,  and  there  breaks.  After  the  opening  of 
these  abscesses,  hectic  but  too  frequently  sets  in,  and  the  patient 
succumbs  to  the  long-continned  suppuration  producing  exhaus- 
tion or  lardaceous  disease  ;  or  he  is  carried  off  by  tubercle  in  the 
lungs  or  other  organs.  Under  more  favorable  circumstances  the 
abscess  may  heal,  firm  ankylosis  of  the  spine  occur,  and  the 
patient  recover  with  a  permanent  hump-back. 

Diagnosis. — In  the  early  stages  caries  must  be  diagnosed  from 
neuralgia,  rheumatism,  lumbago,  aneurysm,  tumors,  and  hysteria  ; 
in  the  later  stages  the  angular  curvature  may  have  to  be  diag- 
nosed from  the  kyphotic  curvature  of  rickets.  From  neuralgia, 
rheumatism,  and  lumbago  it  is  not  always  easy  to  distinguish  it. 
The  history  of  the  former  rheumatic  attack,  the  effect  of  reme- 
dies, and  the  absence  of  the  signs  given  above,  must  then  be  re- 
lied upon.  Hysteria  may  simulate  it  very  closely.  The  absence 
of  signs  of  caries,  except  pain ;  the  inconstant  and  more  diffused 
character  of  the  pain  :  and  the  presence  of  other  signs  of  hysteria 
or  of  uterine  disease,  are  the  points  to  be  attended  to.  A  careful 
auscultation  of  the  chest  and  examination  of  the  abdomen  will 
usually  serve  to  exclude  aneurysm.  From  tumors  of  the  vertebral 
bodies  leading  to  the  breaking  down  of  the  vertebrae  caries  can- 
not at  first  be  diagnosed,  as  both  give  rise  to  the  same  symptoms, 


588 


DISEASES   OF   REGIONS. 


Fig.  278. 


but  the  age  of  the  patient  and  the  presence  of  a  carcinomatous 
growth  elsewhere  would  lead  to  suspicion  of  cancer.  The  curve 
of  rickets  is  more  generally  kyphotic,  and  disappears  more  or  less 
completely  on  gently  holding  the  child  up  by  its  arms,  or  extending 
it  with  its  face  downwards  across  the  nurse's  knees.  There  are, 
moreover,  concomitant  signs  of  rickets,  and  absence  of  those  of 
tubercle. 

Treatment. — Both  constitutional  and  local  measures  are  re- 
quired. The  former  are  those  already  described  under  Tubercle 
(p.  6-^,^.  The  chief  local  indication  is  to  keep  the  spine  at  rest  in 
order  that  the  diseased  vertebrae  may  be  placed  in  the  most  favor- 
able condition  for  repair.  This  may  be  attempted  in  two  ways  :  i. 
By  absolute  recumbency  ;  and  2,  by  the  use  of  some  form  of  spinal 
support.  I.  Absolute  recumbency  from  six  to  twelve  months  in 
the  supine  or  prone  position  on  a  suitably  constructed  couch  is 
the  best  method  of  treatment  where  the  patient  can  be  properly 
cared  for,  has  airy  apartments,  can  be  taken  out  in  this  position 
in  an  invalid  carriage,  and  can  reside  in  the  country  or  at  the  sea- 
side. Especially  is  this  treatment  the  best  when  the  disease  is 
situated  high  up  in  the  spine,  /.  e.,  in  the  upper 
dorsal  or  cervical  region,  and  it  is  imperatively 
necessary  where  there  is  paralysis.  To  ensure  ab- 
solute recumbency  I  have  lately  largely  employed 
a  double  Thomas's  splint  (Fig.  278),  modified  by 
the  addition  of  a  pelvic  band,  a  support  for  the 
shoulders,  neck  and  head,  and  two  sliding  foot- 
pieces.  The  two  upright  bars,  which  are  pro- 
longed to  the  head  support,  are  made  after  the 
shape  of  a  normally  formed  child  when  in  the 
recumbent  position,  and  give  support  to  both 
sides  of  the  spine.  Two  cross-bars  support  the 
body,  just  below  the  axillae  and  pelvis  respec- 
tively ;  the  legs  are  kept  in  position  by  the  or- 
dinary circlets  and  foot-pieces.  The  splint  is 
placed  next  the  skin  so  as  not  to  require  re- 
moval while  the  child  is  washed,  dressed,  etc. 
It  not  only  fixes  the  spine  and  takes  off  the 
w^eight  of  the  head  and  upper  limbs,  but  also 
fixes  the  lower  limbs,  and  thus  prevents  the 
psoas  muscles  from  dragging  on  the  sj)ine.  Ab- 
solute recumbency,  when  ])roijerly  carried  out, 
offers  the  best  ])rospcct  of  averting  serious  an- 
gular deformity  and  paralysis ;  as  soon,  however,  as  the  acute 
symptoms  c)uiet  dcjwn,  some  form  of  spinal  JUpi)ort  should  be 
applied,  and   the  patient  cautiously  allowed   to   take   a   certain 


Double  Thomas's 
splint  for  spinal 
caries. 


CARIES    OF   THE   SPINE.  589 

amount  of  exercise.  But  amongst  the  poor,  where  the  children 
are  often  left  to  themselves  during  the  greater  part  of  the  day, 
absolute  recumbency  can  seldom  be  ensured  ;  and  if  it  could,  its 
advantage  over  other  methods  would  be  counterbalanced  by  the 
severe  detriment  to  the  health  which  the  child  would  suffer  in 
consequence  of  confinement  to  an  ill-ventilated  room,  etc.  For 
such  patients  some  form  of  support,  not  only  to  restrain  as  much 
as  possible  the  motions  of  the  spine,  but  also  to  allow  them  to  ob- 
tain a  certain  amount  of  fresh  air,  is  generally  necessary.  2.  The 
supports  most  in  use  at  the  present  day  are  Sayre's  plaster-of  Paris 
case  and  Cooking's  poroplastic  felt  jacket,  though  some  Surgeons 
still  prefer  steel  instruments.  The  plaster-of- Paris  case  may  be 
applied  with  the  patient  either  in  the  upright  position,  suspended 
with  his  heels  just  off  the  ground  by  Sayre's  tripod,  or  in  the  re- 
cumbent position  by  Davy's  hammock  apparatus.  A  skin-fitting 
vest  having  been  previously  applied,  and  a  line  drawn  across  the 
back  with  a  pencil  at  the  level  of  the  axillae  to  indicate  the  upper 
Hmit  of  the  jacket,  crinoline  bandages,  impregnated  with  plaster- 
of-Paris,  are  wound  round  and  round  the  trunk  till  a  sufficient 
thickness  is  obtained,  dry  plaster  being  from  time  to  time  rubbed 
in  with  the  hands.  The  case  should  reach  from  the  pencil  line  to 
just  below  the  crest  of  the  ilium,  stopping  short  of  the  great 
trochanter  and  the  pubes,  and  may  be  strengthened,  if  necessary, 
in  places  by  inserting  strips  of  perforated  tin  vertically  between 
the  bandages.  Before  applying  the  bandages,  a  folded  silk  hand- 
kerchief should  be  placed  over  the  abdomen  beneath  the  vest,  so 
that  when  afterwards  withdrawn  space  will  be  left  for  abominal 
respiration  {Sayre's  stomach-pad).  When  the  plaster  case  is  dry 
it  may  be  sawn  through  down  the  front,  removed,  and  the  fronts 
edged  with  leather,  and  perforated  with  eyelet-holes,  so  that  it 
can  be  worn  laced  up,  and  be  taken  off  from  to  time.  To  apply 
the  poroplastic  felt,  the  jacket,  which  is  first  made  to  measure, 
must  be  put  in  a  steam  oven,  and  when  rendered  throughly 
plastic,  further  moulded  to  the  patient,  who  should  be  prepared 
and  suspended  in  the  same  way  as  for  applying  plaster-of-Paris. 
Of  steel  instruments,  that  known  as  Taylor's  is  perhaps  the  best. 
In  my  own  practice,  however,  I  almost  invariably  employ  the 
poroplastic  jacket.  Where  the  disease  is  in  the  cervical  or  upper 
dorsal  region,  Sayre's  jury-mast  may  be  fitted  to  the  plaster-of- 
Paris  case  or  poroplastic  jacket ;  or  a  cervical  collar  composed  of 
leather  or  poroplastic  felt  may  be  used,  or  better,  the  combined 
poroplastic  jacket  and  collar  devised  by  the  author.  Should  an 
abscess  form,  it  should  be  treated  in  the  way  described  under 
Chronic  Abscess.  In  some  cases  where  necrosis  has  been  asso- 
ciated with  caries,  success  has  attended  the  removal  of  the  seques- 


59©  DISEASES   OF   REGIONS. 

trum  through  a  properly-planned  incision  made  in  the  loin.  In 
exceptional  cases  in  which  the  paralysis  of  the  lower  limbs  con- 
tinues, in  spite  of  absolute  rest  and  recumbency,  and  in  which 
there  is  intractable  cystitis  or  severe  pain  not  relieved  by  ordi- 
nary measures,  the  spines  and  laminre  of  the  affected  vertebree  may 
be  excised  for  the  purpose  of  relieving  pressure  on  the  cord. 
(Laminectomy.)  The  compression  of  the  cord,  however,  would 
appear  to  more  often  depend  on  the  presence  of  a  tuberculous 
collection  in  front  of  the  cord  than  on  displacement  of  bone. 
Unless  the  tuberculous  abscess,  therefore,  can  be  evacuated,  the 
removal  of  the  arches  of  the  vertebrae  is  futile,  and  only  tends  to 
weaken  the  vertebral  column.  In  place  of  laminectomy,  an  at- 
tempt may,  in  suitable  cases,  be  made  to  reach  the  tuberculous 
collection  from  the  front  of  the  vertebrae.  Menard  has  succeeded 
in  doing  this  by  excising  the  transverse  processes  and  proximal 
end  of  the  ribs  corresponding  to  the  most  prominent  part  of  the 
spinal  curve.  Through  the  aperture  thus  made  he  was  able  to 
scrape  and  wash  away  tuberculous  material  with  the  result  that  the 
paralysis  quickly  disappeared. 

OcciPiTO-ATLOiD,  and  atlo-axoid  disease,  are  terms  applied 
to  chronic  tuberculous  inflammation  attacking  the  articulations 
between  the  occipital  bone  and  the  atlas,  and  the  atlas  and  the 
axis  respectively.  Hence  the  disease  resembles  in  its  course 
tuberculous  disease  of  the  joints,  rather  than  tuberculous  disease 
of  the  bodies  of  the  vertebrae.  It  may  begin  either  in  the  synovial 
membranes,  or  as  caries  of  the  bones  forming  the  articular  pro- 
cesses, and  when  occurring  between  the  atlas  and  the  axis  usually 
affects  the  synovial  membranes  between  the  odontoid  process 
and  the  transverse  ligament  on  the  one  hand,  and  the  tubercle  of 
the  atlas  on  the  other.  Indeed,  in  this  situation  it  would  appear 
to  often  begin  as  a  caries  of  the  odontoid  process  itself,  and  then 
spread  to  the  synovial  membranes.  The  disease  is  often  attri- 
buted to  a  sprain  of  the  neck,  but  though  it  may  sometimes  be 
excited  by  such,  would  appear  more  probably  to  dei)cnd  on 
causes  similar  to  those  leading  to  tuberculous  disease  elsewhere. 

Symptoms. — Pain  is  first  felt  over  the 'seat  of  the  disease,  and 
radiating  in  the  course  of  the  nerves  emerging  from  the  inter- 
vertebral foramina  between  the  affected  bones.  It  is  increased 
on  attempting  to  turn  or  nod  the  head,  but  is  relieved  by  sup- 
porting the  chin  with  the  hand.  Hence  the  patient  often  holds 
his  head  between  his  hands,  and  if  asked  to  rotate  it,  turns  his 
whole  body,  keeping  his  neck  stiff  and  immovable  the  while. 
When  the  disease  is  chiefly  limited  to  the  articulations  between 
the  occipital  bone  and  the  atlas,  the  pain  is  principally  confined 
to  the  region  supplied  by  the  suboccipital  nerve,  and  is  increased 


SPINA    BIFIDA. 


591 


on  nodding  rather  than  on  rotating  the  head.  As  the  disease 
advances,  the  atlas,  with  the  occipital  bone,  has  a  tendency  to 
slip  forward  on  the  axis — directly  forward  if  both  sides  are  equally 
diseased,  or  more  to  one  side  if  the  disease  is  unilateral.  The 
spine  of  the  axis  in  consequence  appears  more  prominent  than 
natural,  and  the  head  on  a  plane  anterior  to  that  of  the  rest  of 
the  spinal  column.  Should  an  abscess  form  it  may  point  at  the 
back  of  the  pharynx  (^post-pharyngeal)  or  at  the  side  of  the  neck. 
Treatment. — Absolute  rest  on  the  back,  with  the  head  between 
sand-bags,  is  imperative,  as  there  is  danger  of  fatal  compression 
of  the  cord  from  the  odontoid  process  or  the  tranverse  hgament 
giving  way  during  some  sudden  movement  of  the  patient.  In 
some  cases  attended  with  paralysis  below  the  disease,  continuous 


Fig.  28 


Spinal  meningocele.  Meningo-myelocele. 

In  the  three  diagrams  (Figs.  279,  280,  and  281)  the  letters  have  the  same  reference.     A. 
Dura  mater,     b.  Parietal,  and  C.  visceral  arachnoid.     D.  Pia  mater.     E.  Cord. 


extension  and  counter-extension,  with  the  patient  in  the  re- 
cumbent position,  has  been  successful  in  removing  the  pressure 
from  the  cord.  When  the  acute  symptoms  have  subsided,  a 
moulded  collar  of  leather  or  poroplastic  felt,  or  an  inflating 
india-rubber  collar,  will  be  required.  Should  an  abscess  form  it 
should  be  opened  in  the  neck  if  possible  rather  than  through  the 
mouth. 

Spina  bifida  "is  a  congenital  malformation  of  the  vertebral 
canal  with  protrusion  of  some  of  its  contents  in  the  form  of  a 
fluid  tumor."  It  is  nearly  always  met  with  in  the  middle  line  of 
the  back,   but   very  exceptionally  the   protrusion  has  occurred 


592 


DISEASES   OF   REGIONS. 


through  the  bodies  of  the  vertebros  instead  of  posteriorly  through 
the  cleft  spines.  It  is  due  to  an  arrest  of  development  of  the 
laminae  of  the  vertebrce  {^mcsoblastic  elements),  and  their  conse- 
quent failure  to  unite  in  the  middle  line  to  form  the  spinous  pro- 
cesses. This  non-union  may  possibly  be  sometimes  owing  to  an 
excess  of  cerebro-spinal  fluid.  A  spina  bifida  may  occur  in  any 
part  of  the  spine,  but  's  most  common  in  the  lumbo-sacral  region, 
where  the  laminae  are  the  latest  to  unite.  It  may  be  associated 
with  partial  paraplegia  or  contracture,  incontinence  of  urine  and 
faeces,  and  with  club-foot  or  other  congenital  deformities. 

Pathology. — Three  chief  forms  of  spina  bifida  are  described  : — 
I,  spinal  meningocele,  2,  meningo-myelocele,  3,  syringo-myelo- 
ele.  I.  In  spinal  meningocele  the  sac  (Fig.  279)  consists  of 
dura  mater  and  arachnoid  blended  together,  and  consequently 
communicates  with  the  sub-arachnoid  space  and  contains  cerebro- 
spinal fluid.  The  cord  and  nerves  remain  in  the  spinal  canal. 
Very  rarely  the  sac  is  said  to  consist  of  dura  mater  only,  /.  e., 
of  dura  mater  and  so-called  parietal  layer  of  arachnoid  ;  it  would 
then  communicate  with  the  subdural  space  instead  of  with  the 
sub-arachnoid.  2.  In  the  meningo-myelocele  (Fig.  280),  the 
most  common  form,  the  sac  also  consists  of  dura  mater  and 
arachnoid,  but  contains  in  addition  to  cerebro-spinal  fluid  the 

spinal  cord  and  nerves,  which  are 
often  spread  out  over  and  inti- 
mately blended  with  the  posterior 
part  of  the  wall  of  the  sac.  As 
the  cord  passes  through  the  sac 
some  of  the  large  nerve-cords  given 
off  from  it  run  forwards  across 
the  interior  of  the  sac  to  re-enter 
the  spinil  canal.  Hence  those 
nerve.;  that  are  given  off  from  the 
cord  where  it  is  adherent  to  the 
sac  wall  appear  to  arise  from  the 
sac,  and  were  in  former  times 
wr  mg'y  described  as  being  dis- 
tributed to  it  (see  Fig.  280).  3, 
In  \}\&  syringo-myelocele  (Fig.  281), 
the  most  rare  form,  the  central  ca- 
nal of  the  cord  is  greatly  distended 
with  fluid,  the  expanded  cord  be- 
ing thus  spread  out  over  the  sac  wall,  with  which  it  is  intimately 
blended.  I'he  nerves  in  this  case  pass  through  the  walls  of  the 
sac  to  their  destinition. 

yiie  coverings  0/ the  sac  may  be  healthy  skin;  but  more  com- 


FlG.  281. 


Syriiigo-mycloi.cle. 


SPINA    BIFIDA.  593 

rnonly  normal  skin  is  only  found  at  the  sides,  the  central  portion 
consisting  of  a  thin  bluish  membrane.  Sometimes  a  slight  de- 
pression is  seen  on  the  lower  part  of  the  sac  at  the  spot  where 
the  cord  terminates  in  the  wall.  This  is  called  the  nmbilictes,  and 
at  its  bottom  the  central  canal  of  the  cord  has  at  times  been  seen 
to  open. 

In  some  instances  there  is  no  protrusion,  but  rather  a  depres- 
sion in  the  situation  of  the  cleft  between  the  vertebra  {spina 
bifida  occulta),  the  cleft  being  occupied  by  the  blended  mem- 
branes, cord,  and  skin,  and  the  spot  covered  with  a  tuft  of  hair. 
In  obscure  paraplegias,  contractures  and  deformities  of  the  feet 
the  back  should  be  examined,  since  this  condition  may  be  pres- 
ent but  have  been  overlooked  by  the  m-other. 

Symptoms. — The  swelling  is  usually  of  a  globular  or  oval  shape, 
translucent,  sessile  or  slightly  pedunculated  and  flaccid,  but  be- 
comes tense  and  distended  on  coughing  or  crying.  Pressing 
upon  it  sometimes  causes  the  fontanelles  to  swell  up,  and  may 
produce  convulsions.  When  the  spinal  cord  and  large  nerves  are 
involved,  there  may  be  paralysis  of  the  extremities  or  of  the 
bladder  or  rectum.  The  gap  between  the  laminae  of  the  verte- 
brae may  at  times  be  felt  on  pressing  on  the  sac.  As  a  rule  these 
tumors  show  a  great  tendency  to  enlarge,  and  rupture  spontane- 
ously, in  which  case  death  usually  follows  from  the  draining  away 
of  the  cerebro-spinal  fluid,  and  septic  meningitis.  Death,  how- 
ever, is  sometimes  due  to  marasmus  and  defective  nutrition. 
When  a  spontaneous  cure  takes  place,  it  is  usually  due  to  the 
gradual  shrinking  of  the  sac. 

Diagnosis. — Its  congenital  origin  v/ill  at  once  distinguish  a 
spina  bifida  from  a  new  growth  developed  subsequently  to  birth ; 
and  its  situation  in  the  middle  line,  translucency,  increase  of  ten- 
sion on  straining,  and  the  gap  between  the  laminae,  when  this  can 
be  felt,  will  usually  seive  to  diagnose  it  from  other  congenital 
tumors. 

Treatment. — As  there  are  no  means  of  accurately  determining 
that  the  spinal  cord  is  not  in  the  sac,  it  has  hitherto  not  been  con- 
sidered safe  to  attempt  excision  or  ligature,  although  these  opera- 
tions have  at  times  been  attended  with  success.  Repeated  tap- 
pings are  very  fatal.  The  treatment  usually  employed,  except 
when  the  spina  bifida  is  very  small  or  is  apparently  undergoing  a 
spontaneous  cure,  when  it  should  be  left  alone,  is  to  inject  the 
sac  with  Dr.  Morton's  iodo-glycerine  fluid.  This  method  when 
successful  causes  the  tumor  to  shrink,  and  most  closely  follows  the 
process  of  nature  when  a  spontaneous  cure  occurs.  The  injection 
is  best  performed  when  the  child  is  two  months  old  ;  but  it 
may  be  done  earher  if  the  sac  threatens  to  burst.  "The  best  re- 
25* 


594  DISEASES   OF   REGIONS. 

suits  may  be  expected  when  there  is  no  hydrocephalus  or  paraly- 
sis, and  the  sac  is  covered  by  healthy  skin."  It  is  contraindi- 
cated  when  there  is  "  advanced  marasmus,  great  and  increasing 
hydrocephalus,  and  intercurrent  disease."  The  child  should  be 
placed  on  its  side,  and  the  puncture  made  obliquely  through 
healthy  skin  on  one  side,  and  the  base  of  the  tumor,  and  not 
through  the  thin  and  imperfectly  formed  skin,  which  nearly  always 
covers  the  sac  in  the  middle  line,  "  the  object  being  to  avoid 
wounding  the  expanded  spinal  cord,  and  the  subsequent  leakage 
of  the  cerebro-spinal  fluid."  About  a  drachm  of  the  iodo-glycer- 
ine  fluid  (iodine  grs.  x.  ;  iodide  of  potassium,  grs.  xxx. ;  glycer- 
ine, 5J.)  should  be  injected,  and  the  injection  repeated  in  a  fort- 
night if  the  first  trial  is  not  successful.  The  fluid  contained  in  the 
sac  should  not  be  drawn  ofl"  before  the  injection.  The  advantage 
of  Morton's  fluid  over  tincture  of  iodine  alone  is  that  owing  to  the 
glycerine  it  contains,  it  becomes  uniformly  diffused  over  the  sac 
walls.  The  injection  of  iodo-glycerine  is  not  unattended  with 
danger ;  therefore  when  the  sac  is  small  and  its  walls  are  thick, 
and  it  is  not  increasing  in  size,  beyond  protecting  it  with  a  metal 
or  leather  shield,  no  further  treatment  should  be  attempted. 
Mayo  Robson  advocates  excision  in  all  cases  except  where  there 
is  well  marked  paraplegia,  hydrocephalus  or  marasmus,  or  where 
the  tumor  is  small  and  well  covered  by  a  firm  pad  of  integument. 
In  spinal  meningocele  he  makes  skin  flaps,  removes  the  sac,  liga- 
tures or  sutures  the  base,  and  brings  the  flaps  together  by  suture. 
In  meningo-myelocele  he  separates  the  skin  from  the  sac,  opens 
the  sac,  dissects  the  nerves  and  cord  from  the  sac  wall,  returns 
them  into  the  spinal  canal,  removes  the  sac,  ligatures  or  sutures 
the  meningeal  pedicle,  and  brings  the  skin  flaps  together  over  it, 
taking  care  that  the  lines  of  suture  in  the  meninges  and  skin  are 
not  placed  opposite  each  other. 


SURGICAL  DISEASES  OF  THE  INTESTINES. 
IN'JKSTINAL  ODSl RUCTION. 

The  pathological  conditions  that  may  give  rise  to  intestinal  ob- 
struction are  very  various,  and  may  be  considered  under  the  fol- 
lowing heads : 

I.  Impaction  of  fteces  or  foreign  bodies  in  the  intestines. — 
Accumulation  of  hardened  faeces  may  occur  as  the  result  of  habit- 
ual or  accidental  constipation,  and  is  then  nearly  always  met  with 
in  the  large  bowel,  and  especially  in  the  region  of  the  caecum  or 
in  the  sigmoid  flexure  and  rectum.  The  impaction  of  gall-stones 
or  intestinal  concretions,  though  more  rare,  is  also  met  with  in  the 


INTESTINAL   OBSTRUCTION.  595 

small  intestines.     Obstruction  from  these  causes  is  more  common 
in  women  than  in  men. 

2.  Internal  ste angulation  or  internal  hernia. — These  terms 
are  applied  to  obstruction  of  the  intestine  by  some  constricting 
agent  within  the  abdomen.  The  strangulation  may  be  effected 
by:  I.  Bands  produced  by  the  stretching  of  old  inflammatory 
adhesions,  the  result  of  former  peritonitis.  These  are  more  par- 
ticularly common  about  the  mouths  of  old  hernial  sacs.  2.  The 
remains  of  some  foetal  structure,  as  the  omphalo-mesenteric  duct, 
Meckel's  diverticulum,  etc.  3.  A  coil  of  intestine  slipping  through 
a  hole  in  the  mesentery  or  omentum.  4.  A  coil  of  intestine  pass- 
ing into  a  pouch  of  peritoneum  {^retroperitojieal  hernia)  as  the 
duodeno-jejunal,  the  sigmoid,  or  one  of  the  ileo-csecal  pouches. 

3.  Volvulus  is  a  twisting  or  kinking  of  a  coil  of  intestine,  so 
that  its  calibre  is  completely  obliterated  at  the  twisted  or  bent 
spot.  Accumulation  of  flatus,  excessive  peristalsis  due  to  gall- 
stones, constipation  and  unequal  distension,  have  been  assigned  as 
causes.  Volvulus  is  said  to  be  most  common  in  the  sigmoid  flex- 
ure ;  and  always  to  be  situated  towards  the  back  of  the  abdominal 
cavity.  The  intestine  may  be — i,  simply  bent  upon  itself;'  2. 
twisted  round  its  mesentery ;  and  3,  wound  round  another  coil  of 
intestine.  The  first  form  only  occurs  in  the  colon ;  the  second  in 
the  small  intestine  ;  the  third  form  usually  consists  of  the  colon 
wound  round  a  coil  of  small  intestine,  the  sigmoid  flexure,  or  the 
caecum. 

4.  Intussusception  (Fig.  282)  is  the  invagination  of  a  portion 
of  intestine  into  the  lumen  of  the  intestine  immediately  below. 
The  intestine  thus  forms  three  tubes,  one  within  the  other,  an 
outer,  middle,  and  inner  (Fig.  283).  The  external  tube  is  called 
the  sheath,  or  intussiiscipiens,  the  innermost  the  entering  tube,  the 
middle  the  receding  or  inverted  tube,  the  last  two  together  being 
further  called  the  intussuscepted  portion,  or  intusstcsceptum.  Thus, 
there  are  two  peritoneal  and  two  mucous  surfaces  of  the  intestine 
in  contact  (Fig.  283),  and  between  the  inner  and  middle  tubes  is  a 
portion  of  the  mesentery  or  meso-colon,  which  is  necessarily  drawn 
down  with  the  intestine.  The  dragging  of  the  mesentery  causes 
the  intussusceptum  to  assume  a  greater  curve  than  its  sheath,  and 
hence  to  become  puckered  along  its  concavity ;  it  also  causes  the 
orifice  of  the  intussusceptum  to  be  directed  towards  the  mesen- 
teric attachment  and  to  be  slit-like  in  shape.  The  intussuscep- 
tion nearly  always  increases  at  the  expense  of  the  lower  portion  of 
the  intestine,  the  sheath  becoming  more  and  more  infolded,  so 
that,  if  the  intussusception  occurs  at  the  lower  part  of  the  ileum,  no 
more  of  the  ileum  will  be  involved,  but  the  caecum  and  colon  may 
be  gradually  drawn  in.     More  rarely,  however,  the  ileum  is  pro- 


596 


DISEASES   OF   REGIONS. 


truded  through  the  ileo-caecal  valve;  the  intussusception  then 
increases  at  the  expense  of  the  upper  portion  of  the  intestine, 
more  and  more  of  the  ileum  being  protruded  through  the  valve. 
This  variety  is  known  as  the  ileo- colic,  in  contradistinction  to  the 
former,  which  is  called  ileo-ccecal.  At  first  the  invagination  is 
reducible,  and  is  not  attended  with  any  serious  obstruction  to  the 
lumen  of  the  intestine.  In  this  condition  it  may  remain,  in 
chronic  cases,  for  several  weeks  or  months.  Or  the  mucous 
membrane  of  the  intussusceptum  may  become  congested  and 
swollen,  rendering  reduction  difiicult  or  impossible  without  rup- 
ture or  other  injury  of  the  intestine.  In  the  majority  of  cases, 
however,  especially  in  infants,  if  the  intussusception  is  not  soon 
reUeved,  the  blood-vessels  of  the  involuted  mesentery  rapidly  be- 


FlG.  28 


Fig.  283. 


Intussusception.     (.St.  Bartholomew's 
Hospital  Musium.) 


Diagram  of  intussusception. 


come  constricted  where  the  latter  enters  the  sheath,  causing 
acute  obstruction  to  the  circulation  in  the  receding  tube.  As  a 
consequence  of  this,  the  mucous  membrane  becomes  intensely  con- 
gested, and  pours  out  the  sanious  discharge  so  diagnostic  of  the 
disease.  In  the  meanwhile,  the  contiguous  peritoneal  .surfaces  of 
the  inner  and  middle  tube  become  intlamed  and  glued  together, 
rendering  reduction  imjjossible.  (langrene  of  the  intussuscej^tum 
now  ensues,  and  the  patient  .usually  dies  of  collapse  or  peritonitis 
in  a  few  days.  In  adults,  however,  and  in  children  of  six  or  eight 
years  and  upwards,  the  gangrenous  portion  may  slough  off  at  the 
constricted  part  and  be  passed  per  anum,  but  in  children  under 
two  years  of  age,  the  disease,  unless  relieved  by  treatment,  is  al- 


INTESTINAL    OBSTRUCTION.  597 

most  invariably  fatal.  Should  recovery  take  place  in  this  manner 
the  patient  may  subsequently  succumb  to  stricture  of  the  intes- 
tine from  contraction  occurring  at  the  spot  where  the  intestine 
has  united.  The  intussusception  may  measure  only  two  or 
three  inches  in  length,  or  it  may  involve  the  whole  of  the  large 
intestine  and  protrude  at  the  anus.  It  is  attributed  to  worms,  the 
dragging  of  a  polypus,  an  elongated  mesentery,  irregular  peri- 
stalsis, diarrhoea,  and  external  violence.  Its  most  common  situa- 
tion is  at  the  ileo-csecal  valve,  then  in  the  small  intestine,  and  then 
in  the  colon.  It  is  rare  in  adults,  t)ut  common  in  children,  espe- 
cially in  infants. 

5.  Stricture  of  the  intestine  consequent  upon  disease  of 
THE  intestinal  WALL. — This  Condition  is  generally  due  to  the 
growth  of  a  carcinoma  or  other  tumor,  more  rarely  to  contractions 
following  ulceration,  the  passage  of  gall-stones,  or  injury,  or  opera- 
tion on  the  intestine.  It  is  most  frequently  met  with  in  the  large 
intestine,  especially  the  rectum  and  lower  part  of  the  colon  and 
caecum  ;  it  is  rare  in  the  small  intestine. 

6.  Contractions  of  the  intestine  consequent  upon  disease 
beginning  external  to  the  intestinal  wall. — This  condition 
may  depend  on  chroiiic  peritonitis,  or  on  carcinoma  of  the 
omentum  or  mesentery.  It  is  more  common  in  the  small  than  in 
the  large  intestine,  and  not  only  narrows  the  calibre  of  the  bowel, 
but  also  obstructs  the  peristaltic  action  by  gluing  the  coils  of  in- 
testine to  one  another  and  causing  contraction  of  the  mesentery. 

7.  Acute  peritonitis  and  enteritis  are  not  uncommon  causes 
of  intestinal  obstruction.  Peritonitis  is  a  frequent  termination  of 
the  other  conditions  that  cause  obstruction,  but  it  is  perhaps  most 
often  due  to  inflammation  spreading  from  the  region  of  the  caecum 
(ypei'i-iyphlitis) ,  the  bursting  of  a  peri-typhlitic  abscess  into  the 
peritoneal  cavity,  or  to  ulceration,  perforation,  or  gangrene  of  the 
vermiform  appendix. 

7.  Typhlitis  and  peri -typhlitis,  or  inflammation  in  and  about 
the  caecum,  may  possibly  sometimes  be  due  to  the  lodgment  of  a 
faecal  mass  in  the  cscum,  but  is  much  more  freqnendy  started  by 
the  impaction  of  a  foreign  body,  as  a  pin  or  a  fruit  or  gall-stone 
or  little  mass  of  hardened  fjeces,  in  the  vermiform  appendix.  It 
is  apt  to  recur  from  time  to  time  {recurrent  typhlitis,  ap/eiidicitis). 
In  such  cases,  ulceration,  perforation  or  gangrene  of  the  appendix 
is  very  apt  to  take  place  and  set  up  {a)  general  septic  peritonitis, 
or  {b)  locahzed  peritonitis.  In  the  latter  case  the  peritonitis 
may  remain  locahzed  and  terminate  in  a  peri-typhlitic  abscess, 
which  may  be  either  intra-  or  retro-peritoneal,  or  may  spread  to 
the  general  peritoneal  cavity  and  become  diffuse. 

9.  Mechanical   pressure   on   the   intestine  by  innocent  or 


598  DISEASES   OF   REGIONS. 

malignant   growths,,  hydatid   cysts,   enlarged    glands,    etc.,    may 
occasionally  give  rise  to  obstruction. 

10.  Congenital  malformation  of  the  intestine. — Amongst 
the  chief  of  these  may  be  mentioned  imperforate  anus,  deficiency 
of  the  rectum,  absence  of  the  colon,  termination  of  the  colon  in 
the  bladder,  etc.  Obstructions  from  such  and  like  causes  are 
only  met  with  in  the  infant  {see  Diseases  of  Rectum,  p.  652). 

11.  External  hernia. — All  forms  of  external  hernicC  when 
strangulated,  and  generally  when  incarcerated  or  inflamed,  are 
productive  of  intestinal  obstruction  {see  Hernia,  p.  6ig). 

Termination  of  intestinal  obstruction. — Whatever  the  cause  of 
the  obstruction,  the  intestine  above  becomes  sooner  or  later 
enormously  distended  with  faecal  matter  (Fig.  287)  and  flatus, 
and  if  the  obstruction  be  not  removed  the  case  will  end  fatally 
from  exhaustion,  peritonitis,  ulceration  or  rupture,  followed  by 
collapse  and  peritonitis,  or  septic  poisoning  by  the  toxines  of  the 
bacillus  coli  {colibacillosis). 

The  SYMPTOisis  of  intestinal  obstruction  vary  according  to  the 
pathological  conditions  upon  which  the  obstruction  depends. 
The  symptoms  common  to  all  may  be  said  generally  to  be  pain, 
vomiting,  constipation,  and  more  or  less  distension  of  the 
abdomen.  AVhen  the  obstruction  occurs  suddenly,  and  is  attended 
by  stiangulation  of  a  portion  of  intestine,  as  in  i,  the  various 
forms  of  constriction  produced  by  bands  ;  2,  a  portion  of  intestine 
slipping  through  a  hole  in  the  mesentery  or  omentum  ;  3,  volvulus  ; 
and  4,  external  strangulated  hernia,  the  symptoms  are  also  sudden 
in  their  onset  and  acute  in  their  course,  as  is  likewise  generally 
the  case  when  they  depend  upon  intussusception,  the  impaction 
of  a  gall-stone  or  other  foreign  body,  the  sudden  accumulation  of 
faeces  above  a  stricture,  or  acute  enteritis  or  peritonitis.  Thus 
the  pain  is  severe  and  violent,  and  occurs  suddenly  in  a  ])erson 
in  previously  good  health  ;  the  vomiting  comes  on  early,  and 
may  rapidly  become  faecal ;  the  constipation  is  complete  from 
the  first ;  flatus  will  not  pass  by  the  anus  ;  the  urine  may  be 
scanty  or  suppressed  ;  there  is  frequently  hiccough  or  tympanites  ; 
and  the  patient  soon  falls  into  a  state  of  collapse  and  dies. 
When,  on  the  other  hand,  the  obstruction  comes  on  more  slowly, 
and  a  portion  of  intestine  is  obstructed,  rather  than  strangulated, 
as  from  (1)  progressive  stricture  of  the  rectum  or  colon;  (2) 
the  pressure  of  an  abdominal  or  pelvic  tumor;  (3)  the  gluing  of 
the  intestines  together  by  chronic  peritonitis  or  cancer ;  (4)  the 
gradual  accumulation  of  faeces,  due  to  habitual  constipation,  and 
(5)  chronic  intussusception,  the  symptoms  are  also  insidious  in 
their  onset  and  chronic  in  their  course.  Thus,  obscure  abdom- 
inal symptoms  may  have  existed  for  some  time.     The  pain  is 


INTESTINAL   OBSTRUCTION.  599 

less  severe,  more  diffused,  and  may  be  intermittent,  but  increases 
with  the  distension.  Vomiting  only  occurs  late  in  the  course  of 
the  affection,  and  does  not  become  faecal  till  towards  the  last. 
Constipation  is  not  complete  at  first,  the  motions  may  be 
scybalous,  and  there  may  be  a  history  of  alternating  constipation 
and  diarrhoea.  The  distension  of  the  abdomen  is  gradual  and  is, 
perhaps,  more  marked  in  the  lumbar  and  epigastric  regions.  The 
abdomen  appears  broad,  and  coils  of  intestine  may  be  visible, 
owing  to  increased  peristalsis  consequent  upon  hypertrophy  of 
their  muscular  coat.  The  urine  is  normal.  A  stricture  may 
perhaps  be  felt  in  the  rectum  by  the  finger,  or  in  the  sigmoid 
flexure  by  passing  the  hand.  Collapse  does  not  come  on  till  the 
end.  Such,  broadly,  may  be  said  to  be  the  symptoms  attending 
acute  and  chronic  intestinal  obstruction.  But  it  must  not  be  for- 
gotten that  the  conditions  which  commonly  give  rise  to  chronic 
symptoms  may,  at  any  time,  suddenly  terminate  in  complete 
obstruction  and  strangulation,  when  the  symptoms  will  at  once 
become  acute.  Thus  a  slowly  contracting  stricture  may  become 
suddenly  obstructed  by  the  impaction  of  fseces,  or  by  a  portion 
of  intestine  immediately  above  becoming  invaginated  into  it ;  or 
acute  peritonitis  may  suddenly  supervene,  owing  to  the  giving 
way  of  an  ulcerated  portion  of  intestine  above  a  stricture,  etc. 

The  DIAGNOSIS  of  the  various  pathological  conditions  causing 
obstruction  or  strangulation  of  the  intestines,  though  sometimes 
comparatively  easy,  is  often  very  difficult,  or  even  impossible. 
Your  first  care,  when  called  to  a  patient  with  signs  of  acute 
abdominal  obstruction,  /.  e.,  pain,  vomiting,  constipation,  and 
possibly  distension  of  the  abdomen,  should  be  to  exclude  external 
Strangulated  hernia,  not  merely  contenting  yourself  with  ex- 
amining the  femoral  and  inguinal  rings,  but  also  making  a  careful 
search  in  the  less  common  situations  of  hernia,  as  the  obturator 
foramen  and  sciatic  notch.  Should  there  be  any  fulness,  or  the 
least  suspicion  of  strangulation  in  any  of  these  regions,  an  explo- 
ratory incision  should  be  made.  Having  satisfied  yourself  of  the 
absence  of  external  hernia,  you  should  next  carefully  examine  the 
abdomen  by  inspection,  palpation,  and  percussion,  and  explore 
the  rectum  and  vagina  with  the  finger  ;  whilst  the  former  canal 
may,  in  some  instances,  be  further  examined  by  carefully  passing 
a  long  enema  tube  or  even  by  introducing  the  whole  hand.  At 
times  something  may  be  learnt  by  cautiously  inflating  the  colon 
with  hydrogen  gas,  or  by  slowly  distending  it  by  the  fountain 
syringe  with  fluid,  the  patient  being  in  the  genu-pectoral  position. 
Senn  has  shown  that  gas  v.nll  pass  the  ileo-ceecal  valve,  causing  as 
it  does  so  a  distinct  rushing  sound  with  diminution  of  pressure,  as 
indicated  by  the  mercurial  manometer  attached  to  the  inflating 


600  DISEASES   OF    REGIONS. 

rubber-bag.  If  there  is  no  obstruction  the  gas  can  be  forced 
through  the  whole  intestine  and  out  at  the  mouth.  Should  a 
hernia  be  discovered  exhibiting  well-marked  local  signs  of  stran- 
gulation, or  on  introducing  the  finger  into  the  rectum  a  stricture 
be  felt  or  the  bowel  be  found  loaded  with  hardened  faeces,  blood 
and  slime  escape  from  the  anus  and  a  sausage- shaped  tumor  be 
detected  in  the  abdomen  or  rectum,  or  a  localized  and  tender 
swelling  be  discovered  in  the  right  iliac  fossa,  the  diagnosis  of 
strangulated  hernia,  stricture  of  the  rectum,  impaction  of  hard- 
ened faeces,  intussusception,  and  typhlitis  or  peri-typhlitis  re- 
spectively can  be  readily  made.  But  when,  on  the  other  hand, 
the  hernial  rings  are  found  free,  the  rectum  empty,  and  nothing 
can  be  felt  in  the  abdomen,  the  difficulty  of  localizing  the  cause 
of  the  obstruction  is  great,  and  even  after  the  most  careful  ex- 
amination and  thoughtful  consideration  of  the  symptoms,  it  may 
only  be  possible  to  arrive  at  an  approximate  guess  as  to  the  nature 
of  the  case.  Thus,  if  the  symptoms  are  acute,  the  obstruction 
will  probably  be  due  to  some  form  of  internal  strangulation,  or  to 
a  volvulus  ;  but  it  must  not  be  lost  sight  of  that  it  may  be  due  to 
peri-typhlitis,  acute  enteritis  or  peritonitis,  or  possibly  to  the  im- 
paction of  a  gall-stone.  If  the  symptoms  are  chronic,  it  may  be 
due  to  stricture  in  the  upper  part  of  the  rectum  or  lower  part  of 
the  colon,  malignant  disease  of  the  omentum  or  intestine,  or 
chronic  peritonitis.  If  acute  symptoms  have  been  engrafted  on 
chronic,  it  may  then  be  caused  by  the  impaction  of  faeces  above 
a  stricture,  peritonitis  following  perforation  above  a  stricture  or 
impaction  of  a  foreign  body  in  the  vermiform  appendix,  typhlitis, 
or  peri-typhlitis.  Although  it  may  be  impossible  to  make  a 
diagnosis,  the  following  considerations  may  help  us.  Thus,  if  the 
onset  of  the  symptoms  is  sudden  and  the  patient  is  an  infant  or  a 
young  child,  the  cause  of  the  obstruction  will  probably  be  intus- 
susception or  peritonitis.  If  the  i)atient  is  elderly  or  middle- 
aged,  and  the  symptoms  are  chronic,  malignant  stricture  or  im- 
paction of  faeces  is  the  most  probable  cause.  In  middle  age 
intussusception  is  rare.  The  tendency  to  vomit  is  in  proportion 
to  the  nearness  of  the  obstruction  to  the  stomach,  the  tightness 
of  the  constriction,  and  the  persistence  with  which  food  or  fluid 
has  been  taken  by  the  mouth.  Early  vomiting  implies  tightness 
of  the  stricture ;  violent  retching  or  bile-vomiting  points  to  gall- 
stones ;  faecal  vomiting  only  occurs  when  the  obstruction  is  mod- 
erately low  down.  Vomiting  may  be  absent  in  the  case  of  ob- 
struction of  the  colon  or  rectum.  Mnally,  if  peristalsis  is  visible, 
the  case  is  almost  certainly  not  one  of  acute  peritonitis. 

I.  In  impacted  faces  there  may  be  a  history  of  previous  con- 
stipation, the  rectum  will  probably  be  found  distended,  or  faeces 


INTESTINAL   OBSTRUCTION.  6ot 

will  be  passed  on  the  use  of  enemata.  A  swelling  may  be  felt 
through  the  abdominal  parietes,  and  if  so  will  be  soft,  and  can 
perhaps  be  indented  with  the  fingers.  In  obstruction  from  gall- 
stones, there  may  be  pain  in  the  region  of  the  gall-bladder,  per- 
haps jaundice ;  gall-stones  may  have  passed,  or  similar  attacks 
have  been  previously  suffered  from,  and  the  bowels  may  have 
acted  irregularly.  The  vomiting  is  gastric  or  bilious,  and  is  at- 
tended with  violent  retching. 

In  internal  strangulation  the  attack  is  very  sudden,  and  is 
probably  attributed  to  a  strain ;  the  pain  is  intense,  and  is  re- 
ferred to  one  spot,  or  to  the  umbilicus  ;  vomiting  comes  on  early  ; 
the  constipation  is  sudden ;  there  is  no  desire  to  defaecate ;  the 
urine  is  scanty ;  there  is  no  visible  peristalsis  ;  no  tumor  can  be 
felt ;  there  is  no  haemorrhage  from  the  bowel,  and  no  tenesmus. 
There  is  probably  a  history  of  some  affection  which  might  pro- 
duce bands  of  adhesions,  as  peritonitis,  typhoid  fever,  or  a  former 
hernia ;  or  there  may  have  been  previous  attacks  of  abdominal 
obstruction  with  intervals  of  perfect  health. 

3.  In  volvulus,  the  signs  are  similar  to  the  foregoing,  but  if 
anything  still  more  severe. 

4.  In  intussusception,  when  acute,  there  is  a  discharge  of  mucus 
and  blood  from  the  anus ;  the  abdomen  is  not  much  distended  ; 
the  abdominal  parietes  are  usually  lax,  and  through  them  a 
sausage-shaped  tumor,  doughy  to  the  feel,  hardening  on  handling, 
and  perhaps  changing  its  position  from  time  to  time,  may  some- 
times be  detected  ;  and  the  invaginated  bowel  can  possibly  be  felt 
in  the  rectum.  Collapse  soon  ensues.  When  chronic,  there  may 
have  been  attacks  of  localized  pain  lasting  for  months  before 
strangulation  occurs,  the  patient  having  been  in  good  health  in 
the  intervals.  There  is  straining  and  tenesmus  ;  the  constipation 
is  not  complete  ;  vomiting  is  absent  or  intermittent ;  the  disten- 
sion is  not  marked  ;  and  collapse  does  not  come  on  till  the  end. 
The  tumor  will  have  characters  similar  to  those  mentioned  above. 

5.  In  stricture  the  patient  is  usually  old  or  middle-aged  ;  the 
symptoms  come  on  very  insidiously ;  there  are  alternate  attacks 
of  constipation  and  diarrhoea  ;  the  constipation  gradually  becomes 
more  and  more  pronounced  ;  the  motions  are  probably  lumpy 
{scybalous) ,  pipe-like,  or  flattened  ;  dyspepsia  is  complained  of; 
the  pain  is  diffused  and  depends  upon  the  distension  of  the  ab- 
domen ;  the  distension  comes  on  slowly,  and  is  greatest  in  the 
flanks  ;  peristalsis  is  visible  ;  the  urine  is  copious  ;  the  pulse  quiet ; 
and  vomiting  only  occurs  late  in  the  case.  Having  diagnosed  the 
case  as  one  of  stricture,  the  next  point  to  determine  is  whether  it 
is  situated  in  the  sigmoid  flexure  or  rectum,  and  consequently  that 
opening  the  sigmoid  flexure  in  the  left  groin  or  the  descending 

26 


6o2  DISEASFS   OF   REGIONS. 

colon  in  the  left  loin,  will  be  well  above  the  stricture ;  or  whether 
it  is  situated  in  the  descending,  transverse,  or  ascending  colon,  so 
as  to  necessitate  the  opening  of  the  ascending  colon  or  csecum. 
To  begin  with,  it  should  be  remembered  that  stricture  is  most 
common  in  the  sigmoid  flexure  and  rectum,  next  in  the  colon, 
then  in  the  caecum,  and  is  very  rare  in  the  small  intestine  ;  indeed 
it  is  so  rare  in  the  two  latter  situations,  that  when  its  exact  posi- 
tion is  not  known,  it  is  generally  safe  to  assume  that  right  colo- 
tomy  or  typhlotomy  will  suffice.  Again,  if  the  stricture  is  in  the 
rectum  or  sigmoid  flexure,  the  distension  will  be  equal  on  the  two 
sides  ;  when  in  the  descending  or  transverse  colon,  greater  on  the 
right  than  on  the  left  side.  The  amount  of  distension  on  the  two 
sides  may  be  more  accurately  estimated  by  the  cyrtometer  than 
by  mere  inspection  and  palpation.  If  a  clyster-pipe  will  pass 
for  some  distance,  say  a  foot  or  so,  and  a  large  quantity  of  fluid 
can  be  injected,  the  stricture  is  probably  high  up  ;  but  too  much 
importance  must  not  be  attached  to  this  sign,  as  the  clyster-pipe 
may  have  bent  upon  itself,  and  the  rectum  and  sigmoid  flexure 
are  often  very  capacious.  Further,  something  may  at  times  be 
learnt  by  ausculting  the  colon  whilst  the  injection  is  being  given, 
and  by  passing  the  whole  hand  into  the  rectum.  The  detection 
of  a  tumor  in  any  part  of  the  colon  or  caecum  will,  of  course,  set 
the  diagnosis  at  rest. 

6.  In  contractions  there  is  pain  of  a  paroxysmal  nature  of  short 
duration  and  of  frequent  occurrence ;  peristalsis  may  not  be  visi- 
ble on  account  of  the  matting  together  of  the  intestines,  but 
gurglings  may  be  heard.  There  is  no  vomiting  or  distension  ex- 
cept during  the  attacks  of  pain.  Constipation  is  not  complete ; 
defaecation  is  painless  ;  the  motions  are  not  compressed  or  pipe- 
like as  they  may  be  in  stricture  ;  and  there  is  no  distension  in  the 
flanks.     The  symptoms  may  at  any  time  suddenly  become  acute. 

7.  In  acute  peritonitis  the  abdomen  is  distended  irom  the  first, 
hard,  and  board-like  ;  peristalsis  is  not  visible  ;  the  pain  is  great 
and  increased  on  the  least  pressure  ;  the  pulse  is  small  and  wiry ; 
the  temperature  may  or  may  not  be  raised.  (See  Peritonitis,  p. 
393.)  There  will  jjrobably  be  a  history  of  previous  attacks  of 
typhlitis  or  perityphlitis,  or  signs  of  gastric  ulcer,  or  the  patient  is 
suffering  from  typhoid  fever  or  has  had  uterine  troubles,  etc. 

8.  In  typhlitis  or  perityphlitis  there  is  pain  in  the  region  of  the 
csecum  coming  on  usually  somewhat  suddenly,  nausea  or  vomiting, 
furred  tongue,  constipation  and  fever.  At  first  there  is  in- 
creased resistance  and  tenderness  in  the  right  iliac  fossa,  whilst 
the  rest  of  the  abdomen  may  remain  supple  ;  later  there  is  a  dis- 
tinct swelling  extending  inwards  towards  the  middle  line,  up- 
wards to  about  the  level  of  the  umbilicus,  and  more  or  less  back- 


INTESTINAL   OBSTRUCTION.  603 

wards  into  the  loin.  Still  later,  fluctuation  in  the  swelling  may  be 
detected.  The  tenderness  is  often  most  marked  at  a  spot  two 
inches  from  the  anterior  superior  spine  of  the  ilium,  on  a  line  be- 
tween that  spine  and  the  umbilicus  {McBurnefs  point),  i.  e., 
over  the  situation  of  the  appendix.  There  is  probably  a  history 
of  constipation  or  irregular  action  of  the  bowels,  or  of  one  or 
more  previous  attacks  of  a  similar  nature. 

9.  In  mechanical  pressure  on  the  intestines  by  new  growths, 
cysts,  enlarged  glands,  etc.,  a  tumor  will  probably  be  discovered 
on  palpation  of  the  abdomen  or  by  the  finger  in  the  rectum  or 
vagina. 

10  &  II.  The  diagnoses  of  congenital  7nalfo7'mation  and  exter- 
nal hernia  are  given  under  these  heads  respectively. 

Treatment. — Supposing  any  of  the  above  conditions  to  have 
been  diagnosed  with  tolerable  certainty  (see  above),  the  indica- 
tions for  treatment  will  be  clear.  Where  no  diagnosis,  however, 
can  be  made,  the  treatment  may  at  first  be  expectant,  but  no 
long  delay  is  admissible  if  surgery  is  to  have  a  fair  chance  of  sav- 
ing the  patient.  Thus  in  acute  cases,  nothing  should  be  given  by 
the  mouth  save  small  pieces  of  ice  to  suck,  the  stomach  should 
be  emptied  by  irrigation  with  warm  water  with  the  syphon  stom- 
ach tube,  and  the  patient  placed  under  the  influence  of  morphia 
injected  subcutaneously.  An  enema  may  be  given,  but  purga- 
tives must  of  course  be  avoided.  The  relief,  however,  obtained 
by  these  means  is  often  deceptive,  and  if  the  obstruction  con- 
tinues it  is  worse  thr.n  useless  to  waste  further  time  in  giving 
drugs.  It  is  better  at  once  to  open  and  explore  the  abdomen 
before  irreparatle  harm  has  been  done.  If  when  first  seen  the 
patient  is  already  collapsed  and  his  condition  such  that  he  could 
not  bear  the  shock  attending  exploration,  a  small  incision  may  be 
made  through  the  abdominal  wall,  and  the  first  piece  of  distended 
intestine  that  presents  secured  to  the  edges  of  the  wound,  and 
opened  {Enterotomy).  In  chronic  cases,  the  diet  should  be  re- 
stricted, only  small  quantities  of  the  most  digestible  food  being 
given  at  a  time,  and  as  soon  as  a  diagnosis  can  be  made,  meas- 
ures should  of  course  be  taken  for  relieving,  if  practicable,  the 
obstruction. 

I.  In  impacted  fcEces,  when  medical  means  and  enemata  have 
failed,  the  rectum  may  require  clearing  with  a  scoop  or  other 
suitable  instiument.  In  ol'st/ uction  from  impacted  gall-stones  or 
other  foreign  bodies,  after  the  UdUi.1  remedies  have  been  unsuc- 
cessful, the  abdomen  may  be  cpened,  and  the  gall-stone  or  for- 
eign body  removed  tlirorg'i  an  mcision  in  the  intestine,  or  else 
made  to  pass  by  gentle  m..nii  uLition  ti  rough  the  ileo-caecal  valve. 
The  incision  should  be  made  in  the  longitudinal  axis  of  the  gut, 


6 04  DISEASES  OF  REGIONS. 

and  not  opposite  the  impacted  body  where  the  coats  may  be 
damaged,  but  a  few  inches  lower  down.  The  gall-stone  or  other 
body  may  then  be  removed,  breaking  it  first  if  necessary,  and  the 
wound  be  afterwards  united  by  Lembert's  suture.  Or  should  the 
walls  of  the  gut  be  softened  by  ulceration,  a  portion  of  the  intes- 
tine may  be  resected,  and  the  continuity  of  the  tube  restored  by 
one  of  the  methods  of  enterorrhaphy  described  at  page  382.  An 
impacted  gall-stone  may  sometimes  be  broken  up  with  a  needle 
without  opening  the  intestine. 

2.  In  internal  strangulation,  abdominal  section  is  the  only  pro- 
cedure of  any  avail,  and  ought,  like  herniotomy,  to  be  undertaken 
early  and  not  merely  as  a  last  resource  (see  Laparotomy^. 

3.  In  volvulus  of  the  sigmoid  flexure,  insufflation  with  air  or 
hydrogen,  or  a  large  enema,  will  at  times  succeed  in  untwisting 
the  intestine.  If  these  means  fail,  no  time  should  be  lost  in  open- 
ing the  abdomen  (see  Laparotomy^.  If  there  is  great  distension, 
Treves  advises  that  the  inflated  coil  should  be  punctured  through 
the  abdominal  parietes. 

4.  In  intussusception,  when  acute,  copious  injections  of  warm 
water  to  empty  the  lower  bowel,  followed  by  insufflation  of  air  or 
hydrogen  with  the  patient  inverted  and  thoroughly  relaxed  under 
chloroform,  will  often  succeed  in  the  early  stages,  and  should  be 
given  a  fair  trial.  In  the  meantime  opium  may  be  given  in  doses 
suitable  to  the  age  of  the  patient,  food  withheld,  and  the  stomach 
emptied  by  an  emetic  or  irrigated  with  warm  water.  These 
means  failing,  laparotomy  must  be  performed  (see  Laparotomy), 
If  the  signs  of  strangulation  are  well  marked,  too  much  time 
should  not  be  lost  in  trying  injections  and  insufflation,  lest  the 
bowel  become  so  damaged  or  the  intussusceptum  so  adherent  to 
the  intussuscipiens  as  to  render  the  prospect  of  success  hopeless. 
Indeed,  I  have  come  to  the  conclusion  thnt  unless  laparotomy  for 
intussusception  in  an  infant  is  undertaken  within  twenty-four  to 
thirty-six  hours  fiom  the  onset  of  the  symptoms,  reduction  will  be 
found  next  to  impossible  without  so  injuring  the  intestine  as  to 
render  a  fatal  result  almost  inevitable.  In  infants,  intussuscep- 
tion, unless  relieved  by  injections,  inflations,  etc.,  or  by  early 
oi)erative  means,  may  be  said  to  be  almost  invariably  fatal.  In 
chronic  cases,  although  there  is  less  need  for  early  operative  in- 
terference than  in  acute,  as  the  bowel  may  remain  incarcerated  for 
some  time  before  becoming  strangulated,  it  should  not  be  delayed 
too  long,  lest  the  intussuscepted  portion  become  adherent  to  the 
sheath.  Should  it  appear  ]jrobable  that  this  has  already  hap- 
pened, two  courses  are  oi)en  :  either  to  open  the  abdomen,  or  to 
keep  the  patient  under  the  influence  of  opium  in  the  hope  that 
the  intussusceptum  may  slough  off  and  be  passed  per  anum.     In 


LAPAROTOMY.  605 

exceptional  cases  of  intussusception  of  the  sigmoid  flexure  the 
mass  may  be  drawn  out  of  the  anus,  the  gut  above  and  below 
united  by  sutures,  the  intussusceptum  cut  away,  and  the  united 
gut  reduced, 

5.  For  stricture  of  the  la^'ge  intestine,  left  inguinal  colotomy 
should  be  performed  when  the  obstruction  is  in  the  rectum  or 
lower  part  of  the  sigmoid  flexure,  and  typhlotomy  when  in  the 
transverse  or  descending  colon.  Should  the  strictured  portion  be 
readily  reached  in  performing  the  operation,  it  may,  if  the  disease 
is  localized,  be  cut  out  {colectomy,  typhlectomy),  and  the  bowel 
secured  to  the  wound,  or  better,  the  two  portions  of  bowel  united. 
In  stricture  of  the  small  intestine,  enterotomy  may  be  performed 
as  a  palliative,  or  under  suitable  condidons,  enterectomy  with 
union  of  the  intestines  by  one  of  the  methods  already  described. 

6.  In  contractions,  where  the  intestines  are  matted  together 
by  chronic  peritonitis  or  cancer,  when  medical  means  have  failed, 
enterotomy  may  prove  of  temporary  benefit  by  relieving  the 
distension. 

7.  The  treatment  of  acute  peritonitis  is  given  at  page  394. 

8.  For  an  account  of  the  early  or  medical  treatment  of  typhlitis 
2ind  peri- typhlitis  diVfoxk  on  Medicine  must  be  consulted.  Should, 
however,  the  inflammation  terminate  in  suppuration  and  an  abscess 
form,  it  should  be  opened  and  drained  ;  or  should  such  an  abscess 
burst  into  the  general  peritoneal  cavity,  the  peritoneum  should  be 
washed  out  and  a  glass  drainage  tube  left  in  the  wound.  The 
appendix,  if  found  inflamed,  plugged  with  a  foreign  body,  ulcer- 
ated, or  gangrenous,  should  be  amputated,  and  the  stump  sutured 
by  Lembert's  method.  When  it  appears  that  recurring  attacks  of 
typhlitis  are  due  to  mischief  in  the  appendix  {recurring  appendi- 
citis), the  question  of  removing  the  appendix  after  the  acute  at- 
tack has  subsided  may  be  raised.  The  chief  indications  for  this 
measure  are  {a)  incapacity  of  the  patient  from  the  frequency  of 
the  attacks,  {b)  increasing  severity  of  the  attacks,  (r)  extreme 
danger  of  last  attack,  and  \d)  signs  of  local  suppuration  about  the 
appendix.  The  incision  should  be  made  about  two  inches  from 
the  anterior  superior  spine  of  the  ilium,  at  right  angles  to  a  line 
drawn  from  the  iUac  spine  to  the  umbilicus,  or  over  the  appendix, 
if  this  structure,  as  is  often  the  case  when  swollen  and  thickened, 
can  be  felt.  The  anterior  muscular  band  of  the  caecum  is  at 
times  a  good  guide  to  the  appendix.  Adhesions  having  been 
carefully  separated,  the  appendix  is  removed,  and  the  stump 
sutured  and  covered  by  a  peritoneal  or  omental  graft. 

Laparotomy,  abdominal  section,  or  opening  the  abdomen,  is 
an  operation  that  may  be  required  for  the  purpose  of  exploration 
in  doubtful  cases  of  intestinal  obstruction  or   for  the  relief  of 


6o6 


DISEASES  OF  REGIONS. 


Fig.  284. 


volvulus,  Strangulation  of  the  in  testines  by  bands  or  diverticula,  in- 
tussusception, reduction  of  hernia  en  tnasse,  etc.  The  room 
should  be  at  a  temperature  between  70°  and  80°  Fahr.,  and  the 
patient,  with  the  limbs  wrapped  in  cotton-wool  bandages,  placed  on 
a  rubber  bed  filled  with  hot  water.  The  greatest  care  should  be 
taken  that  nothing  septic  comes  in  contact  with  the  wound  or  peri- 
toneal cavity.  The  stomach  may  be  irrigated  with  warm  water 
before  giving  the  anjesthetic.  This  prevents  vomiting,  and  may 
remove  some  of  the  contents  of  the  upper  part  of  the  intestine 
and  relieve  distension.  Some  Surgeons  give  a  hypodermic  injec- 
tion of  Tsoth  of  a  grain  of  atropine  and  a  rectal  enema  of  brandy 
to  increase  the  heart's  action.  Having  thoroughly  cleansed  the 
skin  with  soap  and  water,  and  afterwards  well  sponged  it  with  car- 

boHc  lotion  (i  in  20)  or  perchloride 
of  mercury  lotion  (i  in  1000),  make 
an  incision  in  the  middle  line  of  the 
abdomen,  midway  between  the  pubes 
and  umbilicus  (Fig.  284,  a),  and 
having  rapidly  exposed  the  peri- 
toncm  and  stopped  all  haemorrhage, 
carefullv  open  the  peritoneal  cavity 
on  a  director.  Some  Surgeons  ad- 
vise that  the  incision  should  be 
limited,  and  only  long  enough  to  at 
first  admit  one  or  two  fingers.  I 
prefer  myself  for  the  purpose  of  sav- 
ing time  to  make  it  long  enough  to 
at  once  admit  the  whole  hand  if 
found  necessary.  If  a  distended 
loop  presents  in  the  wound,  the  ob- 
struction is  in  the  large  or  lower  por- 
tion of  the  small  intestine  ;  if  this 
loop  contains  fluid,  feeces,  or  gas,  it 
is  probably  near  the  obstruction ;  if 
only  gas,  some  distance  off.  Pass 
one  or  two  fingers  or  the  whole  hand 
into  the  abdominal  cavity  and  first  explore  the  hernial  rings  from 
within,  and  if  these  are  free  the  region  of  the  csecu-n,  taking  care 
to  prevent  the  intestines  from  protruding  by  plarins:  over  them  a 
warm  flat  aseptic  sponge.  If  the  Ccccum  is  found  distended,  the 
obstruction  must  be  in  the  large  intestine.  Cairv  your  fingers  or 
hand,  therefore,  along  the  course  of  the  colon  until  the  obstruc- 
tion is  met  with.  If,  on  the  other  hand,  the  crecum  is  empty,  the 
obstruction  must  be  in  the  small  intestine.  Pass  your  fingers  or 
hand  in  this  case  into  the  pelvis,  and  search  for  an  empty  loop  of 


I^ines  of  incision  in  certain  operations 
on  the  abdomen,  a.  Laparotomy, 
Ovariotomy,  b.  Supra-pubic  cyst- 
otomy, c.  Ligature  of  external 
iliac  artery,  d.  Inguinal  colotomy. 
e  (jastrostomy.  f.  Cholccystotomy. 


LAPAROTOMY. 


607 


Fig.  285. 


intestine  below  the  obstruction,  and  follow  the  intestine  by  pass- 
ing it  through  the  fingers  piece  by  piece  till  the  obstruction  is 
discovered.  If  after  a  search  of  some  minutes  the  obstruction  is 
not  found,  enlarge  the  wound  and  allow  the  intestines  to  prolapse, 
keeping  them  warm  by  the  continual  application  of  aseptic  gauze 
wrung  out  of  hot  water.  When  the  intestines  are  much  distended 
Mr.  Greig  Smith  advises  that  the  distended  loop  should  be  drawn 
into  the  wound,  punctured  with  a  Spencer  Wells  ascites  needle 
connected  with  an  aspirator  bottle,  the  distension  relieved,  and 
the  Httle  wound  sutured,  the  Surgeon  waiting  for  hours  at  the 
bedside  if  necessary,  and  aspirating  occasionally  till  the  distension 
is  relieved.  The  gut  in  the  meantime  may  be  kept  in  contact 
with  the  wound  by  a  skewer  passed  under 
it  through  the  mesentery.  In  draining 
the  bowel  a  Paul's  tube  (Fig.  285)  may 
be  used.  The  gut  having  been  drawn 
into  the  wound  and  packed  round  with 
aseptic  gauze^  an  incision  large  enough  to 
admit  the  tube  should  be  made,  the  tube 
(previously  plugged  with  wool)  inserted, 
and  fixed  by  a  ligature  passed  round 
the  flange.  The  plug  of  wool  is  then 
removed  and  rubber  tubing  fixed  to  the 
distal  end  of  the  tube  to  convey  away 
the  faeces.  After  the  distension  is  re- 
lieved the  case  must  be  treated  as  cir- 
cumstances suggest. 

(a)  If  a  loop  of  intestine  is  found  strangulated  in  one  of  the 
hernial  rings,  or  in  a  hole  in  the  mesentery,  it  must  be  released 
from  within  the  abdomen,  dividing  any  stricture  if  necessary,  {d) 
If  a  volvulus  is  discovered  an  attempt  must  be  made  to  untwist 
it,  and  as  a  prophylactic  against  retwisting,  the  mesentery  may  be 
shortened  by  folding  it  upon  itself  parallel  to  the  intestine,  and 
fixing  with  sutures.  If  the  volvulus  cannot  be  reduced,  the  con- 
tents may  be  let  out,  the  wound  sutured,  and  another  attempt 
made.  This  failing,  the  volvulus  may  be  excised  and  the  intes- 
tine restored  by  one  of  the  methods  of  enterorrhaphy  (page  382). 
If  the  patient  is  too  collapsed  to  admit  of  excision,  the  volvulus 
may  be  left,  and  the  intestine  short-circuited  by  means  of  Senn's 
plates,  etc.  If  gangrene  has  occurred,  the  volvulus  must  be  ex- 
cised and  circular  enterorrhaphy  or  lateral  approximation  per- 
formed, (c)  If  a  band  is  met  with  it  must  be  divided.  (^/)  If  a 
large  diverticulum  is  the  cause  of  the  obstruction  it  must  be  cut 
across,  and  the  bowel  end  closed  by  Lembert's  suture,  (e)  If  a 
small  diverticulum  is  producing  the  constriction  it  must  be  severed 


Paul's  glass  tubes  for  draining 
the  intestine.  The  end  with 
the  double  flange  is  inserted 
and  tied  in  the  gut.  (After  Paul.) 


6o8 


DISEASES   OF   REGIONS. 


Fig.  286. 


and  the  two  ends  ligatured.  Should  the  intestine  give  way  in  di- 
viding the  obstructing  band,  etc.,  or  have  already  given  way — if 
the  perforation  is  small  and  the  coats  are  in  a  fairly  healthy  condi- 
tion, the  wound  in  the  intestine  may  be  closed  by  sutures  in  the 
way  described  under  wounds  of  the  intestine.  But  if  the  coats  are 
in  an  inflamed  or  sloughy  condition,  or  gangrenous,  the  diseased 
portion  may  be  excised,  and  the  upper  and  lower  portions  of  the 
intestine  united  in  one  or  other  of  the  ways  already  mentioned 
(page  382).  Only  when  the  patient  is  much  collapsed  should  the 
ends  of  the  bcwel  be  iixed  to  the  external  wound  and  an  artificial 
anus  made.  Before  uniting  the  intestine,  however,  it  may  be  well 
in  some  cases  to  fix  the  intestine  temporarily  in  the  wound  and  let 

the  contents  of  the  distended  por- 
tion drain  away  for  several  hours, 
or  even  dajs.  (/)  If  an  intussus- 
ception is  discovered,  first  squeeze 
out  some  of  the  inflammatory 
oedema  by  steady,  uninterrupted 
manual  compression  with  an  asep- 
tic sponge,  and  endeavor  to  reduce 
the  intussusception  by  gentle  trac- 
tion on  the  bowel  just  above  the 
neck  of  the  intussuscepiens  and  by 
counter- traction  just  below  the 
apex  of  the  intussusceptum ;  or 
better,  try  to  squeeze  out  the  in- 
tussusceptum by  kneading  and 
pressure  from  below.  Reduction 
may  possibly  be  aided  by  insuffla- 
tion of  the  rectum  with  air  or  hy- 
drogen. If  adhesions  have  formed, 
try  to  break  them  down  by  gently 
insinuating  a  probe  between  the 
contiguous  serous  surfaces.  After 
reduction  search  for  any  rent  in  the 
peritoneal  coat  and  bring  it  together  by  suture  and  seal  with  an 
omentum  graft.  Reduction  failirg,  the  following  courses  are 
open:  i.  Exclusion  of  the  intussusception  by  leaving  it  in  situ 
and  short  circuiting  the  intestine  (Fig.  286)  by  forming  a  com- 
munication between  the  bowel  above  and  below  the  intussuscep- 
tion by  means  of  Senn's  and  Murphy's  method.  2.  Complete  or 
partial  excision  of  the  intussusception  and  restoration'of  the  bowel 
by  circular  enterorrhaj  hy,  lateral  af^proximation.  Murphy's  but- 
ton, etc.  Complete  excision  is  a  most  serious  operation,  espe- 
cially when  a  long  length  of  bowel  is  involved.      In  such  a  case, 


Diagram  of  the  method  of  short-circuiting 
the  intestine  for  irreducible  intussus- 
ception. A  c.  Ascending  colon,  c. 
Caicum.     1.   Ileum. 


ENTEROTOMV,  OR  NELATON's  OPERATION.         609 

if  there  is  no  sign  of  gangrene  the  sheath  may  be  opened,  the  in- 
tussusceptum  excised  just  below  its  neck,  the  stump  ligatured,  and 
the  continuity  of  the  intestine  restored  by  lateral  approximation 
by  bone-plates  or  lateral  implantation.  When  gangrene  has 
occurred,  the  whole  intussusception  must  be  excised.  Since  the 
introduction  of  the  more  rapid  methods  of  restoring  the  continu- 
ity of  the  intestine,  the  need  of  making  an  artificial  anus  should 
seldom  occur. 

After  any  of  the  above  operations,  carefully  cleanse  the  abdo- 
men from  blood  by  gentle  sponging  and  close  the  wound  in  the 
parietes,  with  the  two  surfaces  of  the  peritoneum  in  contact,  by 
sutures  passed  through  the  skin  and  peritoneum.  If  in  spite  of 
all  care  the  peritoneum  has  been  soiled  by  faecal  matter,  or  septic 
changes  have  already  started,  flush  out  the  peritoneal  cavity  with 
gallons  of  hot  water  to  which,  some  antiseptic  as  salicyhc  acid  (5 
per  cent.)  or  boracic  acid  (2  per  cent.)  may  be  added.  In 
flushing  out  pass  the  irrigating  tube  amongst  the  intestines  to  the 
back  of  the  abdominal  cavity  and  into  the  pelvis  so  that  the  water 
may  flow  outwards.  If  the  intestines  have  been  allowed  to  pro- 
lapse there  may  be  some  difficulty  in  getting  them  back.  Cover 
them  with  antiseptic  gauze  wrung  out  of  hot  water,  tucking  the 
margins  of  the  gauze  beneath  the  edges  of  the  wound.  Introduce 
the  sutures,  and  when  they  are  all  in  situ  make  uniform  pressure 
on  the  gauze  as  the  sutures  are  tightened  and  tied  from  above 
downwards.  Withdraw  the  gauze  before  the  last  sutures  are  tied. 
Drawing  forward  the  edges  of  the  wound  with  retractors  will 
materially  aid  the  replacement  of  the  intestine.  If  they  cannot 
be  replaced,  draw  a  distended  loop  away  from  the  wound,  aspirate 
or  open  it,  evacuate  as  much  of  the  contents  as  possible,  suture 
the  wound  by  Lembert's  method,  and  again  endeavor  to  replace 
the  prolapsed  intestine.  When  fgecal  soihng  or  septic  changes 
have  occurred,  place  a  glass  drainage  tube  in  the  wound  (see 
Ovariotomy) . 

(g)  If  the  obstruction  is  found  to  depend  on  a  perityphlitic 
abscess  or  acute  peritonitis,  a  rubber  or  glass  drainage  tube  should 
be  placed  in  the  wound  in  the  abdominal  parietes,  after  the  ab- 
scess or  peritoneal  cavity  has  been  washed  out. 

Enterotomy,  or  Nelaton's  operation,  consists  in  opening  the 
abdomen  by  a  short  incision  in  the  middle  line  or  in  the  right  or 
left  groin,  seizing  the  first  piece  of  distended  intestine  that  pre- 
sents, and  securing  it  to  the  wound  by  sutures  and  then  opening 
it.  This  operation  is  employed  in  cases  where  the  obstruction  is 
believed  to  be  in  the  small  intestine,  though  the  diagnosis  of  the 
situation  is  uncertain,  and  where  the  patient's  condition  is  such 
that  the  severe  shock  and  the  prolonged  manipulation  that  neces- 


6ro 


DISEASES   OF   REGIONS. 


Fig.  287. 


sarily  attends  laparotomy  (the  operation  otherwise  indicated) 
would  probably  be  fatal.  It  may  also  be  employed  in  cases  ot 
obstruction  due  to  contractions  consequent  upon  the  matting 
together  of  the  small  intestines  from  chronic  inflammation, 
cancer,  etc.  It  should  be  thoroughly  understood,  however,  that 
the  operation  is  only  Intended  to  relieve  the  distension  of  the  in- 
testines and  prevent  their  rupture.  It  does  not  attack  the  seat  of 
obstruction.  But  by  relieving  the  acute  symptoms  it  may  give 
time  for  a  diagnosis  in  doubtful  cases  to  be  arrived  at ;  and  the 
patient's  condition  after  it  may  so  far  improve  as  to  allow  of  a 
more  radical  course  of  treatment  being  undertaken  on  a  future 
occasion.  The  method  of  Greig  Smith  (p.  607)  is  likely  to  re- 
place to  a  great  extent  the  above  operation. 

Enterectomy  consists  in  opening  the  abdomen  and  excising  a 

portion  of  the  intestine.  It  may 
be  required  for  irreducible  intus- 
susception, carcinomatous  strict- 
ure, gangrene  from  strangulation 
by  bands,  the  closure  of  frecal 
fistulse,  wounds  of  the  intestine, 
etc.  Open  the  abdomen  as  in 
laparotomy  ;  draw  the  portion  of 
intestine  to  be  removed  well  out 
of  the  wound,  and  pack  it  round 
with  moist  antiseptic  gauze  ;  clamp 
the  intestine  with  a  rubber  tube 
passed  through  a  small  incision  in 
the  mesentery  above  and  below, 
to  prevent  the  escape  of  faeces ; 
cut  out  the  diseased  or  damaged 
part ;  tie  all  bleeding  vessels  ;  and 
then  unite  the  intestine  by  one  of 
the  methods  already  described 
(p.  382).  Or  if  the  intestine  is 
much  distended  and  the  patient 
in  a  state  of  extreme  collapse, 
secure  both  the  proximal  and 
distal  portions  of  the  intestine  to 
the  woimd  in  the  abdominal  par- 
ietcs  by  sutures.  After  the  con- 
tents of  the  over-distended  bowel  have  been  evacuated  and  the 
gut  has  regained  its  tone,  the  two  portions  may  be  united  and 
returned  into  the  abdomen.  Fig.  287  represents  a  distended 
caecum  and  lower  portion  of  the  ascending  colon  which  was  re- 
moved for  carcinomatous  stricture  by  my  colleague,  Mr.  Langton. 


The  csecum,  with  part  of  the  ascending 
colon  and  the  end  of  the  ileum  removed 
for  cancer  of  the  ascending  colon.  The 
cEKCum  was  greatly  distended.  (St. 
liartholomcw's  Hospital  Museum.) 


INGQINAL   COLOTOMY.  6ll 

The  gut  was  united  above  and  below  the  excised  portion  by 
Senn's  plates,  and  the  patient  made  an  excellent  recovery.  For 
the  removal  of  the  caecum  the  incision  should  be  made  in  the 
right  iliac  fossa  (p.  605). 

According  to  whether  small  intestine,  colon,  or  caecum  is  ex- 
cised the  operation  is  spoken  of  as  enterectomy,  colectomy,  and 
typhlectomy. 

Inguinal  colotomy  is  the  operation  of  opening  the  sigmoid 
flexure  of  the  colon  in  the  left  groin  {Littre's  operation).  It  has 
been  much  employed  of  late  in  place  of  lumbar  colotomy,  especi- 
ally for  carcinoma  of  the  rectum  before  distension  of  the  colon 
consequent  on  the  stricture  has  occurred.  Its  chief  advantages 
over  the  lumbar  operation  are  :  i,  that  there  is  less  difficulty  in 
finding  the  gut ;  2,  that  there  is  le^s  danger  of  peritonids,  in  that, 
as  the  peritoneum  has  to  be  opened,  all  proper  precautions  can 
be  taken ;  3,  that  the  wound  is  more  superficial,  and  consequently 
there  is  less  risk  of  infiltration  of  the  tissues  and  septic  poisoning  ; 
and  4,  that  the  groin  is  a  more  convenient  situation  for  an  anus 
than  the  loin.  An  oblique  incision  (Fig.  284,  d)  about  two 
inches  long  is  made  one  inch  from  the  anterior  superior  iliac 
spine,  at  right  angles  to  a  line  drawn  from  the  umbihcus  to  the 
iUac  spine,  one  inch  of  the  incision  being  below  and  one  inch 
above  the  Hne.  Divide  the  skin,  superficial  and  deep  fascia, 
muscles,  fascia  transversalis,  and  the  peritoneum  on  a  director. 
If  the  gut  does  not  present  in  the  wound  carefully  search  for  it 
with  the  fingers.  It  may  be  known  by  the  longitudinal  bands  of 
muscular  fibres,  by  the  appendices  epiploicae,  and  by  its  mesen- 
tery running  to  the  left,  whereas  that  of  the  small  intestine  runs 
to  the  right.  Having  found  the  colon,  introduce  a  flat  sponge 
into  the  wound  to  prevent  the  entrance  of  blood,  and  stitch  the 
parietal  peritoneum  to  the  skin  with  four  sutures.  Remove  the 
sponge  and  draw  down  the  colon  until  the  meso-colon  is  taut,  so 
as  to  avoid  prolapse  of  the  bowel  subsequent  to  the  operation. 
Draw  the  bowel  well  into  the  wound,  pass  a  piece  of  glass  rod 
beneath  it  through  the  meso-colon  so  as  to  produce  a  good  spur, 
and  thus  prevent  the  faeces  going  down  the  distal  end  of  the  in- 
testine, and  secure  the  gut  to  the  parietal  peritoneum  by  sutures 
passed  through  only  the  peritoneal  and  muscular  coats.  Apply 
an  antiseptic  dressing  with  a  piece  of  protective  next  the  bowel 
to  prevent  its  adhering  to  the  gauze,  and  at  the  end  of  three  to 
five  days,  when  adhesions  have  had  time  to  form,  cautiously  open 
the  gut  by  cutting  through  it  on  to  the  glass  rod.  Some  Surgeons, 
for  the  purpose  of  forming  a  spur,  draw  the  gut  forward  by  a  liga- 
ture passed  through  the  mesentery.  Others,  with  the  same  aim 
in  view,   divide  the  colon  and   secure  both  open  ends  to   the 


6l2  DISEASES   OF   REGIONS. 

wound  ;  whilst  others  again  close  the  lower  end  by  means  of 
Lembert's  sutures,  and  drop  it  back  into  the  peritoneal  cavity. 
These  procedures,  in  my  opinion,  add  to  the  risks  of  the  opera- 
tion, and  are,  I  think,  unnecessary  if  the  bowel  is  drawn  well  into 
the  wound  and  a  piece  of  glass  rod  passed  through  the  meso- 
colon in  the  way  above  described.  No  food  should  be  given  by 
the  mouth  for  the  first  twelve  or  twenty-four  hours  and  then  slop 
diet  until  the  gut  is  opened.  If  the  bowel  is  greatly  distended 
at  the  time  of  operation  and  threatening  to  burst,  it  may  be 
opened  at  once  ;  or  should  vomiting  and  distension  come  on  after 
the  operation,  it  may  be  opened  before  the  usual  four  or  five  days 
have  elapsed.  Some  Surgeons  give  opium  as  a  routine  practice, 
others  withhold  it  unless  there  is  pain  or  restlessness.  If  the  bowel 
does  not  act  spontaneously  after  the  gut  has  been  opened,  a  gentle 
saline  purge  or  an  enema  may  later  become  necessary.  The 
bowel  below  the  wound  may  also  require  washing  out  by  an 
enema. 

Lumbar  colotomy  is  the  opening  of  the  colon  in  the  left  lum- 
bar region  (yCalliseti's  operation),  ox  xw  the  right  {Amussafs  oper- 
ation). The  former  should  be  chosen  when  the  disease  is  in  the 
rectum  or  lower  part  of  the  sigmoid  flexure  ;  the  latter  when  there 
is  any  doubt  whether  it  may  not  be  in  the  transverse  colon.  That 
on  the  left  side,  the  common  operation,  need  only  be  described. 
Place  the  patient  on  his  right  side,  slightly  inclining  towards  his 
face,  with  pillows  under  his  abdomen,  or  beneath  his  loin,  in  order 
to  make  his  left  side  prominent.  The  outer  border  of  the  quad- 
ratus  lumborum,  the  guide  to  the  colon,  should  then  be  marked; 
it  is  situated  half  an  inch  posterior  to  a  line  drawn  vertically  up- 
wards from  a  point  midway  between  the  anterior  superior  and 
posterior  superior  spines  of  the  ilium.  Then  make  an  incision 
about  four  inches  long  between  the  last  rib  and  crest  of  the  ilium 
from  the  erector  spinae  obliquely  outwards  and  downwards. 
Divide  the  skin,  fascia,  and  various  layers  of  muscles,  viz.,  the 
latissimus  dorsi,  external  oblique,  internal  oblique,  and  transver- 
salis,  and  the  transversalis  fascia  on  a  director  (Fig.  288),  and  the 
quadratus  lumborum  will  now  be  exposed  at  the  inner  part  of  the 
wound,  and  may  be  known  by  its  fibres  running  upwards  and  in- 
wards. When  the  colon  is  distended  it  will  bulge  in  the  wound ; 
when  contracted,  however,  it  may  be  sought  in  the  wound  by 
carefully  scratching  through  the  fatty  tissue  covering  it  with  two 
pairs  of  dissecting  forceps.  If  there  is  much  difficultly  in  finding 
it,  pass  per  rectum  a  small  catheter,  if  practicable,  through  the 
stricture,  and  inflate  the  colon.  The  colon  may  be  distinguished 
from  the  peritoneum,  which  sometimes  presents  in  the  wound,  by 
its  situation  immediately  external  to  the  (juadratus  lumborum  and 


ASPIRATION   OF   THE   LIVER. 


613 


Diagram  of  parts  divided 
in  left  lumbar  colotomy. 


below  the  kidney  ;  by  the  presence  of  the  longitudinal  bands  of 
muscular  fibres ;  by  the  thickness  of  its  coats  on  nipping  it  up  by 
the  fingers ;  and,  at  times,  by  in  this  way  feeling  scybalous  masses 
of  faeces  in  its  interior.  The  peritoneum,  on  the  other  hand,  may 
generally  be  known  by  the  absence  of  the  above  characters,  and, 
if  it  is  nipped  up,  by  the  intestine  being  felt 
to  sUp  away  from  between  the  fingers.  Hav- 
ing found  the  colon,  secure  it  to  the  skin. 
This  is  usually  done  by  passing  a  silk  suture 
by  means  of  a  curved  needle  on  a  handle, 
first  through  the  skin,  then  through  the 
bowel,  and  then  through  the  skin  on  the 
opposite  side  of  the  wound,  and  repeating 
the  procedure  at  the  other  end  of  the  wound. 
The  bowel  is  then  opened  in  a  longitudinal 
direction,  the  loops  of  suture  by  which  it  is 
transfixed  hooked  out  by  the  finger  and 
divided,  and  the  bowel  secured  to  the  integu- 
ment by  the  four  sutures  thus  formed.  A 
better  and  more  convenient  way  of  passing 
the  sutures,  which  should  then  be  of  wire,  is  by  Smith's  cleft- 
palate  needle.  If  this  is  used  a  series  of  sutures  are  passed,  first 
through  the  skin,  and  then  through  the  wall  of  the  bowel,  and  tied 
before  the  bowel  is  opened.  Should  the  peritoneal  cavity  be 
opened  by  mistake,  it  must  be  carefully  closed  by  suture  before 
the  incision  is  made  into  the  colon. 

Some  perform  lumbar  colotomy  in  two  stages,  like  gastrostomy  ; 
but  if  the  operation  is  carefully  done  in  the  way  described  above, 
such  is  hardly  necessary.  The  bowel  beyond  the  wound  may  sub- 
sequently require  clearing  with  an  enema.  Indeed,  it  has  been 
proposed  to  close  completely  this  part  of  the  bowel  by  operation 
so  as  to  prevent  faeces  passing  down  it. 

OPERATIONS   ON   THE    LIVER,  GALL-BLADDER,    STOMACH,    SPLEEN,    AND 

PANCREAS. 

Aspiration  of  the  liver  is  sometimes  performed  for  the  purpose 
of  diagnosis  in  the  case  of  a  suspected  hydatid  cyst  or  abscess  in 
the  liver,  or  for  the  removal  of  the  fluid  from  an  hydatid  cyst. 
Having  thoroughly  cleansed  the  skin  with  an  antiseptic  and 
placed  the  patient,  if  nervous,  under  an  anaesthetic,  introduce  the 
aspirating  needle  at  the  most  prominent  part  of  the  swelling, 
taking  care  to  avoid  the  colon  and  intestines.  When  operating 
for  hydatids  stop  the  aspiration  if  blood  escapes,  if  the  patient 
becomes  faint,  or  if  violent  cough  comes  on.  Otherwise  continue 
the  aspiration  till  the  cyst  is  emptied.     On  the  removal  of  the 


6 14  DISEASES   OF   REGIONS. 

needle,  place  an  antiseptic  pad  over  the  wound.  The  operation 
is  not  free  from  danger,  several  patients  having  died  suddenly  on 
the  introduction  of  the  needle,  apparently  in  some  cases  from 
plugging  of  the  pulmonary  vein  by  a  portion  of  an  hydatid  that 
has  escaped  into  the  circulation  through  a  wound  of  one  of  the 
hepatic  veins ;  and  general  infection  of  the  peritoneal  cavity  with 
hydatids  has  sometimes  happened.  It  is  better,  therefore,  for  the 
purpose  of  diagnosis,  to  make  an  exploratory  incision  and  to 
evacuate  the  hydatid  or  abscess  in  the  way  described  below. 

Incision  of  the  liver  may  be  required  for  evacuating  an 
hydatid  cyst,  or  abscess.  Make  an  incision  over  the  most  prom- 
inent part  of  the  swelling,  and  having  divided  the  abdominal 
parietes  and  stopped  all  bleeding,  open  the  peritoneal  cavity.  If 
the  liver  is  adherent  to  the  abdominal  walls,  carefully  incise  it,  first 
introducing  an  aspirating-needle  to  determine  the  situation  of  the 
cyst  or  abscess.  If  non-adherent  the  liver  may  be  stitched  to  the 
abdominal  wall,  or  the  prominent  part  well  packed  round  with 
sponges  so  as  to  cut  off  the  general  peritoneal  cavity ;  an  aspirator 
may  then  be  introduced  to  determine  the  situation  of  the  cyst  or 
abscess,  and  the  liver  substance  incised.  Or  the  opening  of  the 
cyst  or  abscess  may  be  delayed  till  the  liver  has  become  adherent 
to  the  parietes.  Great  care  should  be  taken,  if  the  cyst  or  abscess 
is  opened  at  once,  to  prevent  any  fluid  or  pus  escaping  into  the 
peritoneal  cavity,  and  the  strictest  antiseptic  precautions  should 
of  course  be  observed.  In  the  case  oi  a>i  hydatid  €}">(,  after  most 
of  the  fluid  contents  have  been  evacuated  by  the  aspirator  the 
cyst  should  be  opened,  the  daughter  cyst  removed,  and  the  lining 
membrane  shelled  off  the  fibrous  capsule  {jna^supialised),  Xhe. 
edges  of  the  wound  in  the  liver  sutured  to  the  abdominal  wall, 
and  the  cavity  in  the  liver  drained.  If  the  cyst  has  suppurated 
or  an  abscess  is  being  dealt  with,  should  adhesion  not  have  oc- 
curred suture  the  edges  of  the  wound  in  the  liver  to  the  ab- 
dominal walls,  and  place  a  drain  tube  in  the  wound  and  ajiply 
antiseptic  dressings.  If  the  abscess  has  already  ruptured  into  the 
peritoneum,  that  cavity  should  be  thoroughly  washed  out  with  hot 
boric  acid  lotion  and  drained. 

Tapping  the  abdomen  for  ascites  should  be  done  in  the  linea 
alba,  midway  between  the  umbilicus  and  the  pubes  (Fig.  284,  a.). 
The  bladder  having  been  emptied,  a  small  incision  should  be 
made  through  the  skin,  and  the  trocar  and  cannula,  with  a  tube 
attached  to  convey  the  fluid  into  a  vessel,  should  be  thrust  into 
the  abdomen.  The  fluid  should  be  drawn  off  slowly,  and  a  many- 
tailed  bandage,  previously  passed  round  the  body,  gradually 
tightened  as  the  fluid  flows,  in  order  to  keep  up  pressure  on  the 
abdominal  vessels,  and  so  prevent  syncope.     Or  the  fluid  may  be 


CHOLECYSTO-ENTEROSTOMY.  6 1  5 

drawn  off  with  a  Southey's  trocar  and  cannula.  When  this  is  used 
a  skin  incision  is  not  necessary,  nor  is  the  many-tailed  bandage, 
since  the  abdomen  takes  many  hours  to  empty  on  account  of  the 
small  size  of  the  cannula,  and  there  is  thus  no  fear  of  syncope. 

Cholecystotomy  is  the  opening  and  draining  of  the  gall- 
bladder, consequent  upon  the  impaction  of  a  calculus  in  the  cystic 
duct.  Make  a  vertical  incision  in  the  liner  semilunaris,  begin- 
ning just  below  the  ninth  costal  cartilage,  or  over  the  tumor  when 
the  gall-bladder  is  distended  (Fig.  284,  f).  Having  divided  the 
abdominal  parietes  and  stopped  all  bleeding,  open  the  peritoneum. 
Search  for  the  gall-bladder  with  the  finger  beneath  the  liver  if  it 
does  not  present  in  the  wound,  and  bring  it  to  the  surface  if  prac- 
ticable. Pack  the  wound  with  sponges  to  prevent  any  fluid 
escaping  into  the  peritoneal  cavity,  and  introduce  an  aspirator- 
needle  into  the  gall-bladder,  which,  as  the  fluid  escapes,  should 
be  well  drawn  into  the  wound.  Enlarge  the  opening  in  the  gall- 
bladder and  remove  any  gall-stones  found  loose.  If  a  stone  is 
found  impacted  in  the  cystic  duct,  extract  it,  if  possible,  by  for- 
ceps, by  gentle  manipulation  with  the  fingers  in  the  abdomen,  by 
careful  crushing  with  padded  forceps,  by  breaking  it  with  a  needle 
passed  through  the  wall  of  the  duct,  or  by  chipping  off  fragments 
as  it  hes  in  the  duct.  Secure  the  edges  of  the  aperture  in  the 
gall-bladder  to  the  abdominal  wall  by  sutures,  with  its  peritoneal 
coat  well  in  contact  with  the  parietal  peritoneum ;  leave  a  drain- 
tube  in  the  gall-bladder ;  and  close  the  rest  of  the  abdominal 
wound  in  the  way  already  described.  The  biliary  fistula  thus  left 
will  generally  close  in  a  few  weeks  if  the  cystic  duct  has  been 
cleared. 

Cholecysteciomy,  or  extirpation  of  the  gall-bladder,  may  be 
required  :  i,  where  perforation  following  suppuration  and  ulcera- 
tion has  occurred,  and  the  coats  are  found  too  softened  to  admit 
of  suture ;  and  2,  where  cholecystotomy  is  indicated,  but  on 
opening  the  abdomen  the  gall-bladder  is  found  so  contracted  that 
its  fundus  cannot  be  drawn  into  contact  with  the  abdominal  walls 
without  tearing  it.  Make  an  incision  similar  to  that  for  chole- 
cystotomy, prolonging  it  or  dividing  the  muscles  transversely  a 
httle  below  the  ribs  if  more  room  is  required.  Having  well 
packed  the  wound  with  sponges  to  prevent  blood  escaping  into 
the  general  peritoneal  cavity,  dissect  the  gall-bladder  from  the 
liver,  clamping  or  tying  any  bleeding  vessels,  divide  the  cystic 
duct  between  two  ligatures,  cleanse  the  wound,  remove  the 
sponges,  and  unite  the  abdominal  walls  in  the  usual  way. 

Cholecvsto-enterostoimy,  or  the  establishment  of  an  opening 
between  the  gall-bladder  and  the  intestine,  may  occasionally  be 
required  for  immovable  obstruction  of  the  common  bile-duct,  as 


6i6 


DISEASES   OF    REGIONS. 


from  cancer  about  the  head  of  the  pancreas,  duodenum,  etc., 
involving  the  duct.  Hiving  opened  the  abdomen  as  in  other 
operations  on  the  gall-bladder,  draw  the  gall-bladder  and  duode- 
num into  the  wound,  and  having  mide  an  incision  into  each, 
unite  them  by  sutuie,  cr  better,  by  Murphy's  button.  When  the 
latter  method  is  emploved  a  ruining  thread  is  first  passed,  as 
shown  in  Fig.  289,  through  all  the  coats  of  the  duodenum,  and 


Fig,  2 


Method  of  insetting  the  silk  ligature  to  lorm  the  running  thread  for  fixing  Murphy's  button 
in  the  lateral  wall  of  the  intestine.  The  incision  for  the  button  is  seen  within  the  loop  of 
the  thread.     (After  Murphy.) 

then  another  thread  in  like  manner  through  all  the  coats  of  the 
gall-bladder.  An  incision  is  next  made  into  the  duodenum 
within  the  running  thread  (see  Fig.  289)  two-thirds  of  the  length 
of  the  diameter  of  the  button  to  be  used,  the  button  slipped  in, 
and  the  thread  tightly  tied  round  the  central  cylinder  (see  p, 
390).  A  similar  incision  is  made  in  the  gall-bladder,  its  contents 
evacuated,  the  other  half  of  the  button  inserted  and  secured  by 
the  running  thread  in  a  similar  way.  The  two  halves  of  the  but- 
ton, held  by  the  fingers  in  the  way  shown  in  Fig.  290,  are  now 
pressed  together,  thu:s  fixing  the  serous  surfaces  in  contact.  The 
spring  in  the  button  produces  pressure  atrophy  of  the  tissues 
embraced  by  it,  leaving  an  opening  as  large  as  the  button,  which, 
thus  freed,  is  passed  per  anum. 

Pylorpxtomy,  or  removing  the  pylorus  for  carcinoma,  was  for- 
merly done  by  uniting  the  severed  duodenum  to  the  stomach  by 
sutures.  Now  the  cut  ends  of  the  stomach  and  duodenum  are 
usually  sewn  up  by  a  continuous  Lembert  suture,  and  the  stom- 
ach united  to  the  duodenum  or  the  jejunum  by  Senn's  plates 
{V\g.  292),  Murphy's  button,  or  some  other  method  of  lateral 
approximation. 

Gastro-kntkros'iomy  or  forming  a  fistula  between  the  stomach 
and  small  intestine  to  allow  fluids  to  pass  out  of  the  stomach,  is 
employed  (a)  where  the  disease  of  the  pylorus  is  too  extensive  for 
removal;  (h)  after  excision  of  the  pylorus,  to  save  the  time 
required  to  sew  the  stomach  to  the  duodenum,  and  (c)  in  fibrous 


GAS!  RO-ENTEROSTOi\]  Y. 


617 


Stricture  of  the  pylorus  leading  to  dilatation  of  the  stomach.     It 
may  be  done  by  placing  one  of  Senn's  plates  in  the  stomach  and 


Fig.  2qo. 


Male  and  female  half  of  Murphy's  button,  fixed  in  situ  and  ready  for  pressing  together. 
(After  Murphy.) 

Fig.  291. 


Dilatation  of  the  stomach  from  carcinomatous  stricture  of  the  pylorus.     The  stomach  held  ten 
pints.     (St.  Bartholomew's  Hospital  Museum,  No.  1923^.) 

the  other  in  the  termination  of  the  duodenum  or  commencement 
of  the    jejunum,  in  the   way  shown  in  Fig.  292.      A  reaction, 
26* 


6i8 


DISEASES   OF   REGIONS. 


however,  seems  setting  in  against  the  use  of  Senn's  plates,  since  it 
is  thought  by  some  that  they  favor  regurgitation  of  the  contents  of 
the  intestine  into  the  stomach,  and  that  after  their  use  there  is  a 
tendency  for  the  aperture  between  the  viscera  to  contract.  By 
Postnikow  the  jejunum  is  attached  to  the  front  of  the  stomach  by 
a  row  of  sutures  passing  only  through  the  serous  and  muscular 


Fig.  292. 


Part  of  the  stomach  and  jejunum  from  a  case  of  gastroenterostomy  for  malignant  growth  at 
thepylorus.  A.  Stomach.  B.  Jejunum.  The  bone  plates  are  still  i>i  situ.  The  plate  in 
the  jejunum  is  seen.     (St.  Bartholomew's  Hospital  ftluseum.) 

coats ;  then  in  front  of  the  line  of  sutures  oval  portions  of  the 
serous  coat  of  each  viscus  are  removed  ;  the  exposed  muscular 
coat  and  underlying  mucosa  of  each  viscus  are  next  pinched  up 
and  tightly  ligatured  so  as  to  cause  them  to  slough,  and  the  raw 
edges  of  the  serous  coats  united  each  to  each  by  non-penetrating 
sutures.     Another  row  of  stitches  are  finally  inserted  in  front. 

DuODENOSTOMY  AND  JEJUNOSTOMV,  OX  the  Operations  for  forming 
an  artificial  opening  into  these  portions  of  the  small  intestine  re- 
spectively, are  so  rarely  required  that  they  are  not  here  described. 
Neither  is  the  operation  of  opening  the  stomach,  securing  it  to 
the  abdominal  walls,  and  then  scraping  away  with  a  curette  por- 
tions of  the  carcinoma  blocking  the  pylorus.  Indeed,  gastro- 
enterostomy by  the  improved  methods  has  practically  replaced 
these  operations.  The  nefcessity  for  the  large  number  of  Lam- 
bert's sutures  formerly  employed  in  gastro-enterostomy  is  now 
done  away  with,  and  the  operation  can  consequently  be  performed 
in  a  very  much  shorter  time,  ancl  hence  with  much  less  shock. 
Many  successful  cases  have  been  recorded. 

Dilatation  of  the  caroiac  and  i-viokic  ends  of  the  stomach 
FOR  SIMPLE  fibrous  S'lKiCJURE  (Loic/d^i  flpera/ton)  consists  in 
opening  the  stomach  and  then  dilating  the  cardiac  or  pyloric  end, 


HERNIA.  619 

as  the  case  may  be,  with  the  finger.  The  wound  in  the  stomach 
is  then  closed  by  Lembert's  suture,  and  the  abdominal  parietes 
united,  as  after  ovariotomy.  The  strictest  antiseptic  precautions 
must  of  course  be  taken.  In  the  successful  operations  there  has 
been  no  return  of  the  stricture  at  present. 

Pyloroplasty,  which  has  been  successfully  employed  for  non- 
mahgnant  stricture,  consists  in  dividing  the  pylorus  longitudinally, 
widely  retracting  the  margins  of  the  wound,  and  then  uniting 
them  by  suture  in  such  a  way  as  to  leave  the  incision  transverse. 

Splenectomy,  or  extirpation  of  the  spleen,  may  be  required  for 
rupture  of  the  viscus,  and  for  some  cases  of  hypertrophy.  An  in- 
cision is  made  either  in  the  linea  alba,  the  linea  semilunaris,  or 
still  further  to  the  left,  and  the  spleen  having  been  thoroughly  ex- 
posed, adhesions  carefully  broken  down,  and  the  organ,  if  en- 
larged, drawn  out  of  the  wound,  the  pedicle  is  transfixed  in 
several  places,  and  the  ligatures  interlocked  and  tied.  The  pedi- 
cle is  next  severed  well  to  the  splenic  side  of  the  ligatures,  the 
organ  removed,  the  peritoneum  thoroughly  cleansed,  and  the  ab- 
dominal wound  united  and  drained.  Great  care  should  be  taken 
not  to  tear  the  splenic  substance,  an  accident  attended  with  fear- 
ful haemorrhage. 

Drainage  of  pancreatic  cysts  due  to  obstruction  of  the  duct 
or  to  injury  may  be  required.  These  cysts  give  rise  to  a  tumor 
in  the  epigastrium,  which  is  often  attended  with  severe  neuralgic 
pain,  and  from  which  may  be  obtained  on  aspiration  an  alkaline 
fluid  having  the  properties  of  turning  starch  into  sugar  and  of 
emulsifying  fats.  Fat  may  be  present  in  the  faeces  and  sugar  in 
the  urine.  The  abdomen  should  be  opened  and  the  cyst  stitched 
to  the  abdominal  wall  and  drained.  Lloyd  beheves  that  many  of 
these  so-called  cysts  are  due  to  haemorrhage  into  the  lesser  sac 
of  the  peritoneum,  the  result  of  injury,  whilst  Swain  attributes 
them  to  rupture  of  a  retention-cyst  of  the  pancreas  into  the  lesser 
sac. 


The  term  Hernia,  though  often  used  in  conjunction  with  other 
terms  to  signify  the  protrusion  of  any  viscus  from  its  containing 
cavity,  as  '^'^  Hernia  cerebri,'''  or  "Hernia  testis,''  when  employed 
alone  is  applied  only  to  such  a  protrusion  from  the  abdomen  or 
pelvis,  and  is  equivalent  in  this  sense  to  the  term  rupture,  the 
name  by  which  the  affection  is  popularly  known. 

Description  of  hernia  in  general. — A  hernia  may  occur  at 
almost  any  situation,  but  is  most  common  at  the  inguinal  and 
femoral  rings,  spots  at  which  the  abdominal  parietes  are  naturally 
weaker  than  elsewhere.     It  generally  consists  of  intestine,  or  of 


620  DISEASES   OF   REGIONS. 

omentum,  or  of  both  ;  but  almost  every  one  of  the  abdominal  or 
pelvic  viscera  have  at  times  formed  the  protrusion. 

The  causes  of  hernia  are  predisposing  and  exciting.  The 
p?rdisposing  m^-j  ht  divided  into:  i.  Hereditary  and  congenital 
malformations,  such  as  an  elongated  condition  of  the  mesentery, 
a  patency  of  the  funicular  portion  of  the  tunica  vaginalis  or  canal 
of  Nuck,  and  congenital  defects  of  the  abdominal  parietes.  2. 
Acquired  elongation  or  downward  displacement  of  the  attach- 
ment of  the  mesentery.  3.  A  relaxed  condition  of  the  abdominal 
muscles,  such  as  is  induced  by  pregnancy,  and  by  rapid  emacia- 
tion in  persons  previously  stout.  4.  The  rapid  formation  of  fat 
in  the  omentum  or  mesentery.  5.  Any  injury  or  operation  that 
has  weakened  the  abdominal  walls.  6.  Occupations  involving 
severe  muscular  exertion  ;  and  7.  The  male  sex,  inasmuch  as 
men  are  more  subject  to  the  exciting  causes.  The  exciting  causes 
are  such  as  produce  a  diminution  in  the  size  of  the  abdominal 
cavity  by  the  contraction  of  the  muscles  forming  its  walls  and  the 
consequent  compression  of  the  contained  viscera.  They  may  be 
divided  into  those  that  act  suddenly,  and  those  that  act  slowly. 
Amongst  the  former  may  be  mentioned  sudden  and  violent 
exertions,  straining  at  stool,  lifting  heavy  weights,  etc.  x'\mongst 
the  latter,  continual  straining,  as  from  stricture  of  the  urethra, 
enlarged  prostate,  phimosis,  or  a  narrow  meatus,  constant  cough- 
ing occasioned  by  chronic  bronchitis  and  emphysema,  etc. 

Anatomy  of  hernia. — As  the  viscus  is  protruded  through  the 
abdominal  or  pelvic  parietes,  whether  at  one  of  the  so-called 
rings  or  elsewhere,  it  generally  forces  that  portion  of  the  parietal 
peritoneum  which  lies  over  the  aperture,  before  it  in  the  form  of 
a  pouch.  When  it  escapes  at  the  internal  inguinal  ring,  how- 
ever, instead  of  thus  protruding  the  peritoneum  in  front  of  it,  it 
may  pass  into  the  tubular  prolongation  of  peritoneum  which 
naturally  descends  in  front  of  the  testicle  in  the  foetus,  and  which 
from  some  cause  has  ren)ained  unobliterated.  The  pouch  of 
peritoneum  in  which  the  protruded  viscus  is  thus  enclosed  is 
called  the  sac.  In  the  former  case  it  is  spoken  of  as  an  acquired, 
in  the  latter  as  a  co7igeniial  sac.  In  some  forms  of  caecal  hernia 
the  sac  may  be  incomplete,  /.  e.,  the  viscus  may  be  only  covered 
by  peritoneum  m  front,  and  in  contact  with  the  tissues  behind  ; 
and  in  diaphragmatic  hernia,  and  in  hernia  following  a  wound  of 
the  abdominal  walls  where  there  is  no  parietal  peritoneum  cover- 
ing the  aperture,  there  will  be  no  sac.  The  protruded  viscus 
enclosed  in  its  peritoneal  sac  forms  a  swelling  surrounded  by  the 
tissues  of  the  part  into  which  it  has  escaped.  The  tissues  super- 
ficial to  it,  i.  e.,  between  the  sac  and  the  skin,  form  what  are 
called  its  coverings.  We  have  to  consider,  therefore,  i,  the  sac, 
2,  its  contents,  and  3,  its  coverings. 


REDUCIBLE   HERKIA.  62  1 

1.  The  sac  is  said  to  consist  of  a  body,  neck  and  mouth,  terms 
which  sufficiently  explain  themselves.  It  is  at  first  thin  and 
membraneous,  resembling  the  peritoneum  ;  but  in  old  herni^e  may 
become  thickened  and  indiur.ttd,  cr  else,  as  for  example  in  um- 
bilical hernia,  attenuated  or  in  plue.s  absorbed.  It  is  usually 
globular  or  pyriform,  but  may  take  almost  any  shape.  Thus  it 
may  be  fusiform,  hour-glass-like,  or  divided  by  adhesions  into 
two  parts,  the  lower  part,  perhaps,  containing  fluid  and  forming 
what  is  known  as  a  hydrocele  of  the  sac.  The  neck  is  at  first 
generally  slightly  puckered,  but  as  the  result  of  inflammatory  con- 
solidation becomes  in  old  hernise  smooth,  thickened,  and  often 
indurated.  The  mouth  may  be  wide  and  expanded,  or,  in  the 
case  of  congenital  herniae,  in  which  the  neck  is  frequently  elon- 
gated, narrow  and  contracted. 

2.  The  contents  of  the  sac  may  be  intestine  alone  {etitej'ocele)  ; 
or  omentum  alone  {epiplocele)  ;  or  both,  the  omentum  then  gen- 
erally descending  in  front  of  the  intestine  {entero-epiplocele^ ,  or 
more  rarely  the  intestine  in  front  of  the  omentum  i^epiplo-ente7-o- 
cele).  In  exceptional  instances  the  bladder,  the  ovaries,  and 
other  of  the  abdominal  or  pelvic  viscera,  have  been  met  with  in 
the  sac.  The  small  intestine,  and  especially  a  portion  of  the 
lower  three  feet  of  the  ileum,  most  frequently  descends.  When 
the  large  intestine  descends  it  is  generally  the  caecum ;  but  any 
portion  of  the  small  or  large  may  do  so.  There  may  be  but  a 
small  knuckle  of  intestine  in  the  sac,  or  a  part  only  of  its  calibre ; 
but  when  once  a  portion  has  escaped  there  is  generally  a  tendency 
for  more  to  follow,  and  in  old  hernise  to  the  extent  of  several 
inches  or  even  feet.  The  protruded  intestine  and  mesentery  in 
long-standing  cases  become  hypervascular  and  thickened,  and  the 
omentum  hypertrophied  and  matted  together.  A  small  quantity 
of  serous  fluid  is  also  generally  found  in  the  sac,  and  in  rare  in- 
stances loose  or  attached  fibrinous  bodies  somewhat  similar  to 
those  met  with  in  bursse.  Where  the  neck  of  the  sac  has  become 
obhterated  by  the  long  wearing  of  a  truss,  the  sac  has  been  found 
filled  entirely  with  serous  fluid,  thus  forming  a  cyst. 

3.  The  coverings  of  the  sac  necessarily  vary  according  to  the 
situation  of  the  hernia.  They  will  be  enumerated  under  each 
special  form,  and  little  more  need  be  said  about  them  here 
further  than  that  they  often  become  thickened,  blended  together, 
thinned,  or  absorbed,  so  that  in  actual  practice  they  can  seldom 
be  demonstrated. 

The  conditions  of  a  hernia. — A  hernia  may  be  :  ( i )  re- 
ducible ;  (2)  irreducible;  (3)  strangulated;  (4)  incarcerated, 
and  (5)  inflamed. 

I.  A  reducible  hernia  is  one  that  can  be  returned  into  the 


62  2  DISEASES   OF   REGIONS. 

abdominal  cavaty  ;  /.  e.,  it  either  goes  back  when  the  patient  Hes 
down ;  or  it  can  be  made  to  do  so  by  the  patient  himself,  or  by 
the  Surgeon  making  pressure  upon  it  in  a  suitable  direction. 
The  sac,  except  perhaps  in  quite  recent  cases,  cannot  be  put 
back  into  the  abdomen  in  consequence  of  its  adhesions  to  the 
surrounding  tissues,  but  remains  empty  ///  situ. 

Symptoms. — At  first  there  may  be  a  mere  fulness  or  protrusion, 
commonly  at  one  of  the  abdominal  rings  ;  the  protrusion  becomes 
more  prominent  when  the  patient  stands  up,  strains,  or  coughs, 
but  it  completely  disappears  on  his  lying  down.  If  neglected  it 
gradually  increases  in  size,  forming  a  prominent  non-translucent 
swelling,  in  which  a  distinct  impulse  is  felt  on  coughing.  If  the 
hernia  contains  intestine  {enterocele),  it  will  be  tense  and  elastic, 
and  resonant  on  percussion  ;  whilst  a  peculiar  gurgling  is  heard 
from  the  displacement  of  gas  and  fluid  on  returning  it  into  the 
abdomen.  If,  on  the  contrary,  it  contains  omentum  {epip/ocele) , 
it  will  be  dull  to  percussion,  doughy  and  inelastic,  or  hard  and 
resisting,  and  lobulated,  whilst  the  characteristic  gurgUng  is  not 
heard  on  returning  it  into  the  abdomen. 

The  diagnosis  will  be  given  under  the  head  of  Special  Hernice, 
as  it  is  from  other  diseases  of  each  special  region  that  a  diagnosis 
has  to  be  made. 

The  treatment  may  be  palliative  or  radical.  The  palliative 
treatment  consists  in  reducing  the  hernia  and  applying  some  form 
of  truss.  A  pad  and  spica  bandage  should  be  applied  (Fig.  293), 
till  a  truss  can  be  procured.  The  form  of  truss  will  vary  accord- 
ing to  the  position,  size,  etc.,  of  the  hernia.  Fig.  294  is  an 
inguinal  truss  of  the  ordinary  shape,  and  may  be  distinguished 
from  a  femoral  (Fig.  295),  by  the  pad  of  the  latter  being  placed 
more  vertically.  Fig.  296  is  an  umbilical  truss.  In  measuring 
for  a  truss  the  following  notes  should  be  taken  and  sent  to  the 
maker: — i.  The  dimensions  round  the  pelvis  midway  between 
the  crest  of  the  ilium  and  the  great  trochanter.  2.  The  kind  of 
hernia.  3  The  side  on  which  it  is  situated.  4.  The  size  of  the 
ring.  5.  The  age  and  sex  of  the  patient.  6.  The  strength  of  the 
spring  required.  The  truss  should  be  worn  constantly,  and  never 
on  any  excuse  be  left  off.  A  lighter  truss  may  be  provided  for  the 
night,  and  one  covered  with  India  rubber  or  made  of  vulcanite  for 
the  bath.  The  /'a^-Z/Vrt;/ treatment  consists  in  reducing  the  hernia, 
and  in  some  way  obliterating  the  sac  and  closing  the  canal  and 
ring.  In  young  children  the  removal  of  the  cause,  as  phimosis, 
etc.,  and  the  wearing  of  a  truss  may  do  this  ;  but  in  older  children, 
and  in  adults,  the  ring  is  usually  too  large  and  otherwise  altered 
for  the  hernia  to  be  thus  cured,  and  some  further  procedure,  if 
thought  advisable,  must  be  undertaken. 


REDUCIBLE   HERNIA. 


623 


Radical  Ctire  of  Hernia. — The  methods  that  have  been  prac- 
tised for  the  radical  cure  of  hernia  are  very  numerous.  Some  of 
them,  as  Wood's,  Spanton's,  Warren's  and  Heaton's  are  practically 
obsolete,  and    will    be    here    no   longer   described.     The    more 


Fig.  293. 


Fig.  294. 


Inguinal  truss. 


Spica  bandage  for  the  groin.     (Brj-- 
ant's  Surgery.) 


Fig.  295. 


Fig.  2q5. 


Umbilical  truss. 


Femoral  truss. 


modern  methods  are  all  founded,  to  a  greater  or  less  extent,  on 
Banks'  operation,  which  consists  in  cutting  away  the  sac  after 
ligature  of  its  neck  and  sewing  up  the  ring.  This  simple  pro- 
cedure, though  often  sufficient  to  insure  a  radical  cure,  is  some- 
times followed  by  a  return  of  the  hernia  ;  hence  more  elaborate 
operations  have  been  introduced.     Most  of  them  are  only  appli- 


624  DISEASES   OF   REGIONS. 

cable  to  inguinal  hernia.  Sufificient  time  has  hardly  elapsed  to 
enable  one  to  say  which  of  the  methods  are  the  most  efficient,  or 
to  what  special  form  of  inguinal  hernia  the  one  or  the  other 
method  may  be  best  adapted.  The  methods  I  have  employed 
myself  of  late  are  a  modified  Banks'  operation  for  simple  cases, 
and  a  modified  Bassini's  for  cases  in  which  the  external  ring  is 
very  large  and  the  canal  more  or  less  obliterated. 

(i)  Macewen's  Method. — Macewen  dissects  up  the  sac  and 

frees  it  as  far  as  the  internal  abdominal  ring  by  introducing  his 

finger  along  the  inguinal  canal.     The  internal  ring  having  been 

reached,  the  peritoneum   is  separated  for 

'^i'^-  =9--  about  half  an  inch  from  the  whole  of  the 

abdominal  aspect  of  the  circumference  of 

the    ring.     The    external    oblique   is    not 

divided.     A  stitch  is  firmly  secured  to  the 

distal  extremity  of  the  sac  and  a  needle 

carrying  the  silk  is  passed  in  a  proximal 

direction  several  times  through  both  layers 

S  of  the  sac,  so  that  when  pulled  upon  the  sac 

Method  of  folding  up  the  sac     bccomes  folded  upou  itself  like  a  curtain 

in   Macewen's   method  of       /t-.-  \         n-.!  ji       •       ii  -u  1  i. 

radical  cure  of  hernia,   s.     (Fig.  297).     The  nccdlc  IS  then  brought 
Sac.   R.  Internal  abdom-     q^j   through   the   anterior  abdominal  wall 

inal   ring,      p,  P.   Parietal       .  °  .  .  1     1        r  i  1     1 

peritoneum.  just  abovc  the  mtcmal  rmg,  and  the  folded 

sac  having  been  pushed  through  the  ring  in 

the  transversalis  fascia  is  secured  there  by  the  silk  suture.     The 

external  abdominal  ring  is  then  laced  up  and  the  skin-incision 

closed  in  the  usual  way. 

(2)  Stanmore  Bishop's  Method. — Stanmore  Bishop  dissects  up 
the  sac  and  frees  it  from  the  surrounding  structures  as  far  as  the 
internal  abdominal  ring.  The  parietal  peritoneum  is  then  sepa- 
rated for  about  half  an  inch  from  the  whole  of  the  abdominal 
aspect  of  the  circumference  of  the  ring.  A  stout  piece  of  aseptic 
silk  armed  at  either  end  with  a  large  curved  Hagedorn's  needle  is 
taken,  and  commencing  at  the  distal  extremity  of  the  sac,  one 
needle  is  made  to  pass  in  a  proximal  direction  along  the  outer  side 
of  the  wall  of  the  sac,  after  the  fashion  of  hemming,  as  far  as  the 
internal  ring,  and  the  other  needle  utilized  in  a  like  manner  on 
the  inner  side  (Fig.  298).  Both  needles  are  then  brought  out 
through  the  abdominal  wall,  on  the  outer  and  inner  sides  of  the 
ring  respectively.  In  this  way  the  sac  is  completely  hemmed 
round  with  a  thread  of  silk,  and  when  traction  is  made  on  the  ends 
of  the  silk  the  sac  is  puckered  up  in  a  mass  (Fig.  299).  Having 
done  this,  the  sac  is  invaginated  with  the  tip  of  the  index  finger  and 
pushed  through  the  internal  ring  while  traction  is  still  being  made. 
The  silk  is  then  tied,  the  internal  ring  thereby  being  closed  and 


REDUCIBLE   HERNIA. 


625 

the  puckered  invaginated  sac  forming  a  button-like  projection  on 
the  abdominal  aspect  of  the  ring  (Fig.  300). 


Fig.  299. 


Fig.  298. 


Method  of  treating  the  sac  in  Bishop's  Method  for  Radical  Cure  of  Hernia,  s.  Sac.  R.  In- 
ternal abdominal  ring.  P  p.  Parietal  peritoneum.  In  Fig.  298  the  sac  is  hemmed  round 
with  a  silk  ligature.  In  Fig.  299  the  sac  is  puckered  upon  outer  side  of  ring.  In  Fig.  300 
the  puckered  sac  is  invaginated,  and  forms  a  button-like  projection  on  abdominal  aspect  of 
ring.     The  silk  ligature  in  all  three  figures  has  a  needle  at  each  end. 

(3)  Barker's  Method. — Barker  dissects  out  only  the  neck  of 
the  sac,  ligatures  it,  and  cuts  it  through  half  an  inch  below  the 
ligature.  The  scrotal  portion  of  the  sac  is  left  /;?  situ.  The  neck 
of  the  sac  is  fixed  to  the  abdominal  wall  by  the  same  ligature  that 
closes  the  internal  ring.  The  external  abdominal  ring  is  next 
laced  up  as  usual. 

(4)  BalPs  Method. — Ball,  of  Dublin,  after  dissecting  out  the 
sac,  recommends  torsion  or  twisting  before  ligaturing  the  neck 
and  cutting  off  the  body  of  the  sac. 

(5)  Halsted's  Method. — Halsted,  of  Baltimore,  makes  an  inci- 
sion parallel  to  Poupart's  hgament  from  the  anterior  superior  spine 
of  the  iliam  to  the  pubic  spine.  He  divides  the  aponeiirosis  of 
the  external  oblique  the  whole  length  of  the  skin  incision.  The 
sac  is  then  dissected  up  and  sutured  by  quilted  sutures  at  as  high 
a  level  as  possible,  and  then  the  lower  portion  is  cut  away.  The 
spermatic  cord  is  now  transplanted  to  the  outer  angle  of  the 
wound  in  the  external  oblique,  and  the  rent  in  the  aponeurosis 
sutured  in  its  entire  extent  beneath  the  cord.  In  this  way  the 
cord  takes  a  subcutaneous  course  and  a  new  inguinal  canal  has 
been  fashioned,  which  passes  outwards  and  upwards  from  the 
internal  abdominal  ring. 

27 


d26 


DISEASES   OF   REGIONS. 


Fig.  301. 


(6)  McBurnefs  Method. — McBurney,  of  New  York,  treats  the 
wound  by  open  incision  after  dissecting  out  and  ligaturing  the 
sac.  He  endeavors  to  keep  the  wound  an  open  one  by  turning  in 
the  integument  and  suturingit  to  the  deep  fascia.  He  then  packs 
it  with  iodoform  gauze  and  allows  the  wound  to  granulate.  The 
wound  takes  from  three  to  six  weeks  to  heal,  but  the  firm  scar 
left  completely  obliterates  the  inguinal  canal. 

(7 )  Bassi?ii's  Method  {s/ightly  modified). — An  incision  is  made 

from  the  internal  to  the  exter- 
nal ring  parallel  to  and  about 
^-inch  above  Poupart's  liga- 
ment. The  external  ring  having 
been  defined,  the  aponeurosis 
of  the  external  oblique  is 
divided  from  the  apex  of  the 
ring  the  whole  length  of  the 
skin- incision.  The  sac  is  next 
defined,  cleared  with  the  finger 
as  high  as  the  internal  ring,  the 
neck  ligatured  and  the  body  cut 
away.  The  cord  is  now  lifted 
out  of  the  inguinal  canal  and 
held  aside  by  a  silk  ligature 
passed  lightly  beneath  it  (Fig. 
301,  b).  The  internal  oblique, 
with  the  transversalis  and  trans- 
versalis  fascia,  is  next  separated 
from  the  aponeurosis  of  the  ex- 
ternal oblique  and  from  the 
peritoneum,  and  sewn  by  four 
or  five  silk  sutures  to  the  deep 
internal  surface  of  Poupart's 
ligament,  which  should  have 
been  previously  defined.  In 
PMg.  301  two  of  the  sutures 
(d,  e)  are  seen  in  situ.  When 
all  the  sutures  have  been  passed 
they  are  tied  beneath  the  cord  and  thus  ]nill  the  conjoined  tendon 
of  the  internal  oblicjue  and  transversalis  with-  the  transversalis 
fascia  firmly  downwards  and  outwards,  and  thus  form  a  firm  pos- 
terior wall  to  the  inguinal  canal.  The  aponeurosis  is  now  united 
by  a  continuous  suture  (Fig.  301,  H),and  the  skin-wound  closed. 

(8)  Radical  Cure  of  Fc7noi-al  Hernia. — Make  an  incision  over 
the  hernia  from  a  little  above  Poupart's  ligament  vertically  down- 
wards about  2j/  inches.     Having  freed  the  sac,  opened  it,  and 


Method  of  applying  the  sutures  in  the  radical 
cure  of  hernia  by  the  modified  .  Bassini 
Method.  A.  Aponeurosis  of  external  ob- 
lique turned  down,  n.  .Silkligature holding 
spermatic  cord  F  aside,  c.  Director  re- 
tracting the  upper  margin  of  the  divided 
aponeurosis  of  the  external  oblique.  D  and 
E.  Two  of  the  deep  sutures  passed  through 
the  deep  internal  surface  of  Poupart's  liga- 
ment and  conjoined  tendon,  c.  The  con- 
joined tendon  of  the  internal  oblique  and 
transversalis  and  transversalis  fascia.  H. 
Continuous  suture  for  sewing  up  ihe  divided 
aponeurosis  of  the  external  oblique.  I,  i. 
The  skin,  in  which  some  of  the  spots  are  in- 
dicated at  which  the  skin  sutures  should  be 
passed.  • 


IRREDUCIBLE    HERNIA.  627 

returned  its  contents,  clear  the  neck  with  the  finger  passed  up  the 
femoral  canal  Ligature  the  neck  ;  cut  away  the  body  of  the  sac, 
and  with  the  aid  of  Macewen's  needles  carry  the  two  ends  of  the 
ligature  which  has  been  tied  round  the  neck  up  the  femoral  canal 
anterior  to  the  peritoneum,  and  make  them  emerge  through  the 
abdominal  wall  just  above  the  round  ligament  or  spermatic  cord, 
about  yl  of  an  inch  apart.  On  tying  the  two  ends  of  the  liga- 
ture the  sac  will  be  drawn  well  behind  the  abdominal  parietes. 
Whilst  passing  the  ligatures  protect  the  femoral  vein  with  the 
finger,  and  draw  up  the  skin  incision  that  the  needles  may  emerge 
in  the  wound.  On  letting  go  the  skin,  the  knot  of  the  hgature 
will  be  covered  by  it.  Next  sew  Hey's  ligament  to  Cooper's  liga- 
ment (a  band  of  strong  ligamentous  fibres  running  along  the  pec- 
tineal ridge  of  the  pubes)  by  one  or  two  silk  sutures,  thus  closing 
the  femoral  canal. 

(9)  The  radical cu7-e  of  U77ibilical  hernia  may  be  done  by  re- 
moving the  sac,  refreshing  the  edges  of  the  ring,  and  bringing  the 
wound  together  with  the  peritoneal  surfaces  in  contact ;  or  if  the 
ring  is  very  large  and  its  margins  are  dense,  then  a  large  flange 
stitch  may  be  used  (Fig.  302),  as  practised  by  Greig  Sm.ith.  The 
cicatricial  tissue  is  divided  all  round  the  ring  at  its  free  margin, 
down  to  the  rectus  muscle,  and  the  sutures  passed  first  through  the 
upper  fibrous  edge,  then  through  the  rectus,  then  through  the 
lower  fibrous  edge  on  one  side  of  the  wound,  and  then  in  the  re- 
verse order  through  the  tissues  on  the  other  side. 

2.  An  IRREDUCIBLE  HERNIA  is  ouc  that  cannot  be  returned  into 
the  abdomen. 

The  causes  of  the  irreducibility,  which  are  many,  may  be  con- 
veniently classified  according  as  the  impediment  to  the  return  of 
the  contents  of  the  sac  exists  :  i.  Outside  the  sac,  from  inflamma- 
tory thickening  and  contraction  of  the  tissues  forming  the  ring  or 
other  aperture  through  which  the  hernia  has  escaped.  2.  In  the 
sac  walls,  from  the  inflammatory  thickening  and  contraction,  and 
from  elongation  of  the  neck  of  the  sac.  3.  Inside  the  sac,  from 
(«)  the  great  bulk  of  the  intestine  or  omentum  due  to  increased 
growth  subsequent  to  their  descent ;  {b)  constriction  of  the 
omentum  at  the  situation  of  the  ring  and  expansion  of  the  lower 
part ;  (r)  adhesion  of  the  intestine  or  omentum  to  the  sac,  or  to 
one  another  ;  (<•/)  bands  of  adhesions  stretching  across  the  sac, 
and  so  confining  a  loop  of  intestine  or  knuckle  of  omentum  ;  (^)  a 
collection  of  fluid  in  the  sac;  (/)  a  portion  of  intestine  (as  the 
caecum)  having  descended  uncovered  with  peritoneum  on  one 
aspect,  the  uncovered  portion  forming  adhesions  with  the  tissues 
around  it  where  the  sac  is  absent. 

The  symptoms  are  similar  to  those  of  the  reducible  form,  save 


628 


DISEASE?  OF   REGIONS. 


that  the  hernia  cannot  be  completely  reduced.  Thus,  there  is 
impulse  on  coughing,  non-translucency,  and  when  it  contains  in- 
testine, gurgling  on  handling,  and  resonance  on  percussion.     It 


Fig.  302. 


Greig  Smith's  method  of  performing  the  radical  cure  ol  umbilical  hernia.  A.  Tran.sverse  sec- 
tion through  hernia  and  parietcs,  showing  sac,  contents,  ring,  and  lines  of  incision,  i  N. 
Intestine,  o  M.  Omentum,  s  K.  Skin.  F.  Fascia,  thickened  at  margin  of  ring.  M.  Rec- 
tus muscle,  p.  Peritoneum,  i.  Incision  through  the  skin  of  sac,  which  is  continued  along 
the  subperitoneal  tissue  to  margin  of  rmg.  2.  Same  on  opposite  side.  Between  i  and  2 
skin  and  sac  are  removed  on  free  surface,  and  sac  on  deep  aspect.  3  and  4.  Incisions  car- 
ried deeply  through  thickened  fascia  round  umbilical  ring  10  expose  recti.  H.  Gut  returned, 
omentum  removed,  superfluous  skin  and  sac  removed,  sutures  placed,  incisions  in  fascia 
opened  up  and  recti  exposed.  References  same  as  in  A.  C.  Sutures  tied,  .skin  .suture  to 
one  side  of  parietal  line  of  junction.  D.  Bird's-eye-view  showing  double  set  of  sutures 
around  umbilical   ring  and  cutaneous  wound.     I, From  a  drawing  by  .Mr.  Greig  Smith.) 


i.s,  moreover,  often  attended  with  dragging  or  colicky  pains  and 
dyspeptic  symptoms.  When  its  contents  are  both  intestine  and 
omentum,  the  intestine  can  sometimes  be  returned.  A  consid- 
eration of  the  above  signs  should  serve  to  distinguish  it  from  a 
hydrocele  extending  high  up  the  cord,  with  which  it  is  perhaps 


STRAJS'GULATED    HERNIA.  '  629 

most  likely  to  be  confounded.  An  irreducible  hernia  often  attains 
a  large  size,  and  is  not  only  on  this  account  a  constant  source  of 
annoyance  to  the  patient,  but  is  also  one  of  danger,  as  there  is  al- 
ways a  risk  of  its  becoming  obstructed,  strangulated,  or  inflamed, 
or  ruptured  by  accidental  blows,  etc.  The  treatment  may  be 
directed  to  one  of  two  ends  :  i,  to  protect  the  hernia  from  injury 
and  prevent  it  from  getting  bigger  by  the  descent  of  more  intes- 
tine or  omentum  ;  and  2,  if  possible,  to  render  it  reducible,  or 
better,  if  the  patient's  general  state  of  health  is  favorable,  to  cure 
it,  by  one  of  the  radical  o|)erations  already  described.  For  the 
first  purpose  the  patient  should  wear  a 
bag   truss    (Fig.   303),   or  the    lace-up  Fig.  30^!. 

truss.  Trusses  are  often  difficult  to  ad- 
just. Under  such  circumstances  a  cast 
of  the  parts  should  be  taken  in  plaster- 
of-Faris,  and  to  this  any  instrument- 
maker  can  then  accurately  mould  the 
truss.  When  the  patient  will  submit,  an 
attempt  may  be  made  to  convert  the 
hernia  into  a  reducible  one  ;  and  if  per-  \ 

severed  in  will  frequently,  especially  in  Bag  truss  for  irreducible  hernia. 
recent  hernige,  be  successful.   The  patient 

should  maintain  the  horizontal  position,  the  diet  should  be  re- 
stricted, saline  purgatives  given,  and  ice  occasionally  applied  to 
the  part,  or  continuous  pressure  may  be  kept  on  the  hernia  by 
means  of  the  hinge- cup  truss.  This  treatment  will,  of  course, 
only  be  successful  when  the  irreducibility  depends  upon  remov- 
able causes,  such  as  an  increase  in  the  bulk  of  the  omentum  or 
intestine.  When  due  to  adhesions  and  the  like,  it  cannot  be 
thus  overcome,  though  with  the  use  of  the  hinge-cup  truss  ad- 
hesions if  not  too  firni  may  gradually  elongate  and  disappear. 
Seeing,  however,  that  strangulation  may  occur  notwithstanding 
the  use  of  a  truss,  other  things  being  equal,  I  always  myself  advise 
a  radical  cure. 

3.  Str-angulated  hernia. — This  form  of  hernia  is  one  in  which 
the  protruded  portion  of  intestine  or  omentum  is  so  tightly 
gripped,  that  not  only  is  its  return  into  the  abdomen  prevented, 
but  the  circulation  through  its  blood-vessels  is  so  impeded  that 
congestion,  followed  by  inflammation  and  gangrene,  speedily  en- 
sues, if  the  strangulation  is  not  soon  relieved. 

Causes. —  I.  The  sudden  forcing  of  intestine  or  omentum 
through  a  ring  or  aperture  so  small  that  it  is  tightly  gripped  from 
the  moment  of  its  descent.  This  is  usually  the  cause  of  strangu- 
lation in  a  recent  hernia  or  in  an  old  hernia  which  has  suddenly 
descended   through  the  patient's  neglect  to  put  on  his  truss.     2. 


630  DISEASES   OF    REGIONS. 

The  increase  of  bulk  in  the  hernia  subsequent  to  its  descent,  and 
its  consequent  constriction  where  it  passes  through  the  aperture 
or  ring.  This  is  usually  the  cause  of  strangulation  in  irreducible 
herniae,  or  in  hernife  that  have  not  been  kept  up  by  a  truss.  Such 
an  increase  in  bulk  may  be  induced  by:  {a)  the  sudden  pro- 
trusion of  a  fresh  portion  of  omentum  or  intestine  on  the  top  of 
that  already  down  ;  (^)  the  swelling  of  the  intestine  from  catarrhal 
inflammation  of  the  mucous  membrane,  or  from  its  becoming  ob- 
structed by  faeces  or  flatus  ;  and  (r)  congestion  and  inflammation 
of  the  omentum. 

The  sea/  of  constriction,  or  as  it  is  technically  called  the 
stricture,  is  generally  either  (i)  outside  the  sac,  i.  e.,  at  one  of 
the  tendinous  rings,  or  other  aperture  through  which  the  hernia 
has  passed^  or  (2)  i?i  the  neck  of  the  sack  itself;  whilst  (3)  in 
very  rare  instances,  it  may  be  inside  the  sac,  the  intestine  having 
slipped  through  a  hole  in  the  omentum,  or  become  entangled  by 
a  band  of  adhesions. 

Mechanism  of  strangulation. — The  compression  of  the  veins  at 
the  seat  of  stricture  impedes  the  return  of  venous  blood  from  the 
protruding  portion  of  intestine  or  omentum,  and  the  congestion, 
causing  compression  of  the  arteries,  ultimately  leads  to  the  com- 
plete arrest  of  the  circulation,  and  gangrene  finally  ensues.  The 
congestion,  moreover,  induces  paralysis  of  the  muscular  coat  and 
consequent  cessation  of  its  peristaltic  action  and  the  onward  flow 
of  the  intestinal  contents.  For  strangulation  to  occur  it  is  not 
necessary  for  the  whole  circumference  of  the  bowel  to  be  included 
in  the  stricture.  An  inclusion  of  only  a  small  portion  of  its  cir- 
cumference (Richter's  hernia,  sometimes  incorrectly  called  Littre's 
hernia),  in  consequence  of  the  venous  congestion  and  subsequent 
inflammation  which  it  induces,  is  sufficient.  Indeed,  symptoms 
of  strangulation  are  said  to  occur  when  omentum  only  is  contained 
in  the  hernia,  a  fact  somewhat  difficult  to  explain,  as  constriction 
of  omentum  by  a  tight  ligature  certainly  gives  rise  to  no  symp- 
toms. It  is  possible  that  in  these  cases  the  signs  of  strangulation 
have  depended  on  reflex  irritation  of  the  omental  nerves,  or  on  a 
small  knuckle  of  intestine  having  been  strangulated  at  the  neck 
of  the  sac  and  slipped  back  unperceived.  That  strangulation 
may  produce  a  severe  impression  on  the  nerves  is  evidenced  by 
the  pain  reflected  to  the  umbilicus,  and  by  the  general  nervous 
symptoms. 

Patholoi^ical  condition  (f  the  strangulated  part. — When  the  con- 
striction is  very  tight  the  circulation  may  be  completely  arrested, 
and  gangrene  ensue  in  a  few  hours,  liut  as  a  rule  the  arrest  is 
only  partial,  and  the  gangrene  is  preceded  by  congestion  and 
inflammation.     'I'he  intestine  at  first  appears  red  and,  perhaps. 


STRANGULATED    HERNIA.  63 1 

slightly  swollen,  but  not  otherwise  altered,  whilst  clear  serous 
fluid  in  greater  or  less  quantity  is  poured  out  between  it  and  the 
sac.  It  next  assumes  a  mulberry  color,  and  as  the  congestion 
increases  it  becomes  darker  and  darker,  and  finally  black  or  ash- 
gray.  At  the  same  time  it  becomes  more  swollen,  and  loses  its 
bright  shining  appearance,  becoming  sticky,  then  doughy  in  con- 
sistency, and  pitting  on  pressure,  whilst  the  fluid  gets  darker  and 
turbid,  and  feculent  in  odor ;  finally  the  intestine  sloughs,  and  its 
contents  are  extravasated  into  the  sac.  Sloughing  or  ulceration 
frequently  begins  at  the  seat  of  stricture,  and  in  the  mucous  coat, 
where,  even  at  an  early  stage,  an  impression  of  the  stricture  is 
often  seen.  The  omentum  undergoes  similar  changes,  passing 
gradually  into  a  state  of  gangrene.  The  intestine  above  the  stran- 
gulated portion  for  a  variable  distance  is  congested  and  distended 
with  faecal  matter,  whilst  that  below  is  empty  and  contracted,  but 
otherwise  natural.  Simultaneously  with  these  changes  a  local 
peritonitis  is  set  up  about  the  neck  of  the  sac,  gluing  the  intestine 
to  the  peritoneum,  so  that  as  a  rule  there  is  no  extravasation  into 
the  peritoneal  cavity.  The  sac  becomes  inflamed,  a  faecal  abscess 
is  formed,  and,  if  the  patient  survives,  opens  on  the  surface,  leav- 
ing him  with  a  faecal  fistula.  In  other  cases  general  peritonitis 
supervenes,  or  the  mtestine  gives  way  above  the  stricture,  and  so 
peritonitis  results. 

The  symptoms  are  local  and  general.  Local  symptoms. — The 
hernia,  if  previously  reducible,  is  no  longer  so  ;  it  becomes  tender 
or  painful  on  handling,  tense,  and  often  tympanitic  ;  and  the  im- 
pulse 071  coughing  is  lost.  Pain  may  be  present  in  the  hernia,  but 
is  generally  referred  to  the  region  of  the  umbilicus.  The  skin  is 
usually  natural,  but  where  gangrene  has  occurred  it  may  become 
mottled,  or  brick-dust  red,  and  emphysematous,  and  exhale  a 
faecal  odor.  Cessation  of  pain  may  then  occur,  but  is  a  delusive 
sign.  The  general  symptoms  are  those  of  intestinal  obstruction, 
the  two  chief  being  vomiting  and  constipation.  The  vomiting  is 
of  a  peculiar  gushing  character,  with  httle  or  no  retching.  The 
vomit  at  first  consists  of  the  contents  of  the  stomach,  but  soon 
becomes  bile-stained,  and  finally  fascal,  /.  <?.,  thin  and  brownish- 
yellow,  with  a  distinct  odor  of  faeces.  The  constipation  is  com- 
plete (except  in  Richter's  hernia),  flatus  not  even  passing,  al- 
though at  first  the  contents  of  the  large  intestine  may  be  voided, 
either  naturally  or  after  an  enema.  The  face  becomes  pinched 
and  anxious,  the  pulse  small  and  wiry,  the  tongue  furred  and 
brown,  and  if  strangulation  is  not  relieved  the  patient  may  die  of 
collapse,  general  peritonitis,  or  exhaustion  from  constant  vomiting. 
Very  occasionally  a  faecal  abscess  may  form  and  the  patient  re- 
cover with  a  fsecal  fistula.     Space  will  not  permit  of  a  description 


632  DISEASES   OF   REGIONS. 

of  the  variations  in  the  symptoms  that  may  be  met  with,  and  it 
must  suffice  to  say  that  as  a  rule  in  young  patients  with  recent 
hernia  they  are  more  acute,  and  call  more  imperatively  for  imme- 
diate relief  than  in  older  patients,  the  subjects  of  irreducible  her- 
nia of  long  standing,  in  whom  they  assume  a  more  chronic  char- 
acter. 

Treatment. — It  cannot  be  too  strongly  impressed  on  the  mind 
of  the  student  that  it  is  of  vital  importance  to  release  the  strangu- 
lated intestine  ;  that  this  as  a  rule  admits  of  no  delay  ;  that  every 
hour  adds  to  the  danger  (gangrene  may  occur  within  twenty-four 
hours)  ;  that  the  result  of  the  case  will  depend  to  a  great  extent 
upon  the  length  of  time  the  strangulation  has  existed  ;  that  pur- 
gatives for  overcoming  the  obstruction  are  not  only  useless,  but 
absolutely  injurious;  and  that  prolonged  and  forcible  attempts  to 
return  the  bowel  by  the  taxis  are  unjustifiable  and  wholly  to  be 
condemned.  What  should  be  done,  therefore,  in  a  case  of  stran- 
gulated hernia  ?  The  taxis  should  as  a  rule  be  applied  for  a  few 
minutes  ;  if  this  is  unsuccessful  the  patient  may  in  some  forms  of 
inguinal  hernia  be  put  in  a  warm  bath  for  twenty  minutes,  and 
another  attempt  then  made  to  return  the  bowel.  This  failing,  he 
should  be  placed  under  an  anaesthetic,  and  should  the  bowel  then 
not  slip  back  readily  on  again  gently  trying  the  taxis,  the  opera- 
tion for  dividing  the  stricture  should  at  once  be  proceeded  with 
before  he  is  allowed  to  recover  from  the  anaesthetic.  If  the  sur 
geon  is  not  prepared  for  the  operation,  or  requires  help,  a  full 
dose  of  opium  should  in  the  meantime  be  given,  and  ice,  if  at 
hand,  or  warmth,  in  the  form  of  a  large  poultice,  be  applied  to 
the  tumor.  But  it  is  better  not  to  attempt  the  reduction  under 
an  anaesthetic  till  prepared  to  proceed  with  the  operation.  We 
have  then  to  consider  the  method  of  applying  the  taxis,  the  cases 
in  which  it  should  not  be  used,  the  cases  suitable  for  the  hot  bath, 
and  the  operation  of  herniotomy. 

The  Taxis. — The  method  of  applying  the  taxis,  which  is  merely 
the  technical  term  given  to  the  various  manipulations  used  in  re- 
turning the  hernia  into  the  abdomen,  can  only  be  learned  by 
practice.  The  pelvis  should  be  slightly  raised,  and  the  thigh  in 
femoral  hernia  flexed  and  adducted  so  as  to  relax  as  much  as 
possible  the  constricting  ring.  With  one  hand,  slightly  raise  the 
hernia,  and  grasp  it  gently  so  that  some  of  the  flatus  or  fluid  may 
be  squeezed  out  and  the  bulk  lessened.  With  the  finger  and 
thumb  of  the  other  hand,  gently  compress  the  neck  laterally  to 
prevent  its  bulging  over  the  margin  of  the  ring,  and  at  the  same 
time  draw  the  hernia  a  little  downwards  to  disengage  its  neck'. 
The  pressure  should  be  applied  steadily,  not  spasmodically,  and 
its  direction  varied  according  to  the  kind  of  hernia.     No  violence 


STRANGULATED    HERNIA.  633 

should  be  used,  and  if  after  a  few  minutes  the  intestine  does  not 
slip  back  with  the  characteristic  rush,  further  attempts  should  not 
be  made.  Violent  or  prolonged  efforts  are  strongly  to  be  con- 
demned, as  not  only  are  they  unlikely  to  be  successful,  but  may 
lead  to  the  rupture  cf  the  intestine,  or  stopping  short  of  this  may 
cause  so  much  bruising,  ecchymosis,  or  inflammation,  that  they 
jeopardize  its  recovery  after  operation.  How  long  shoulii  the 
taxis  be  applied  ?  Certainly  not  more  than  ten  minutes  at  the 
outside.  The  length  of  time,  however,  may  vary  in  different 
herniae.  Roughly  it  may  be  given  at  about  two  minutes  for  a 
small  tight  femoral  hernia,  and  five  minutes  for  a  large  femoral, 
inguinal,  or  umbilical  hernia.  It  should  be  remembered  that  the 
taxis  is  more  successful  in  recent  than  in  old  femoral  hernige ;  in 
inguinal  than  in  femoral,  and  especially  in  old  inguinal  under 
chloroform ;  and  that  when  successful  it  is  the  safest  method  of 
overcoming  the  strangulation.  The  taxis  should  not  be  applied 
—  I,  when  other  surgeons  have  already  employed  it  for  long 
periods  ;  2,  when  the  hernia  is  very  tense,  tender,  or  inflamed  ; 
3,  in  femoral  hernia  where  faecal  vomiting  has  existed  for  some 
time,  or  where  hiccough  has  supervened  ; — in  short,  whenever  it 
appears  questionable  whether  the  intestine  has  not  passed  into  a 
condition  beyond  recovery,  or  whether  actual  gangrene  has  not 
taken  place. 

The  Jiot  bath  is  more  likely  to  succeed  in  acute  than  in  chronic 
cases,  in  young  muscular  patients,  and  in  inguinal  herniae.  It 
should  not,  as  a  rule,  be  given  to  the  old  or  feeble,  as  it  has  then 
a  tendency  to  induce  severe  syncope,  and  renders  them  liable  to 
take  cold.  Little  can  be  expected  from  it  in  femoral  hernia,  on 
account  of  the  fibrous  and  unyielding  nature  of  the  ring. 

77/1?  operation. — Herniotomy  or  kelotomy  has  for  its  object — 
I,  the  liberation  of  the  strangulated  intestine  or  omentum  by  di- 
viding the  stricture,  and  2,  the  returning  it  into  the  abdomen  if 
proper  or  possible.  The  parts  having  been  shaved  and  thoroughly 
cleansed  with  soap  and  water  and  sponged  with  some  antiseptic 
lotion,  an  incision  should  be  made  over  the  sac  in  the  long  axis 
of  the  tumor,  and  its  coverings  carefully  and  successfully  divided 
till  the  sac  is  exposed,  any  bleeding  vessels  being  tied.  The  sac 
may  be  known  by  the  arborescent  arrangement  of  its  vessels,  its 
tenseness  and  smoothness,  and  when  thin  by  intestine,  omentum, 
or  fluid  being  seen  through  it.  It  may  further  be  distinguished 
from  the  intestine  by  the  shining  appearance  of  the  latter,  by  the 
circular  arrangement  of  the  intestinal  vessels,  and  by  a  little  fluid 
usually  escaping  when  the  sac  is  opened.  If  still  in  doubt,  the 
questionable  structure  should  be  picked  up  with  the  thumb  and 
fore-finger  if  not  too  tense,  when,  if  it  is  sac,  the  intestine  will  be 


634  DISEASES    OF    REGIONS. 

felt  to  slip  away.  Before  opening  the  sac,  every  antiseptic  pre- 
caution in  the  widest  sense  of  the  term  should  be  taken.  All 
bleeding  should  be  stopped,  and  the  wound,  the  surgeon's  hands 
and  those  of  his  assistant,  and  the  instruments,  should  be  thoroughly 
cleansed  from  blood  with  antiscpdc  lotion.  A  piece  of  the  sac 
should  be  nipped  up  with  the  forceps,  and  nicked  with  the  blade 

Fig.  304. 


Cooper's  hernia  knife. 

of  the  knife  held  on  the  flat.  If  too  tense  to  allow  of  this,  it  must 
be  cautiously  scratched  through  with  the  point  of  the  knife.  As 
a  rule  there  is  no  danger  of  injuring  the  intestine,  as  some  fluid 
generally  exists  between  the  sac  and  its  contents.  The  sac,  how- 
ever, should  always  be  opened  with  care,  as  the  intestine  may  be 
in  contact  with  it.  If  omentum  is  seen  shining  through  the  sac, 
it  should  be  opened  opposite  that  spot.  The  character  of  the 
fluid  which  escapes  is  a  good  criterion  of  the  condition  of  the 
parts.  If  pale  or  serous,  the  indication  is  good  ;  if  blood  stained 
and  turbid  or  faecal  in  odour,  bad.  A  director  should  now  be 
passed  through  the  small  opening,  and  the  sac  laid  open,  the 
fluid  absorbed  by  sponges  to  prevent  it  running  into  the  abdomen, 
and  the  contents  examined.  If  only  omentum  presents,  this 
should  be  gently  unravelled  to  search  for  intestine,  a  small 
knuckle  of  which  will  often  be  found  near  the  neck  of  the  sac. 
The  questions  will  now  arise,  what  shall  be  done  with  the  intes- 
tine, what  with  the  omentum  ?  Shall  they,  or  can  they  be  re- 
turned? Shall  the  omentum  be  cut  off?  Shall  the  stricture  be 
divided  ? 

Trcaiincni  of  the  intestine. — If  the  intestine  is  merely  congested 
and  claret  colored  but  still  shining,  and  the  fluid  in  the  sac  is  of  a 
serous  character,  there  can  be  no  question  of  replacing  it  in  the 
abdomen  ;  or  if  it  is  already  gangrenous  (a  condition  that  may  be 
known  by  its  ash-gray  color,  loss  of  elasticity  and  not  bleeding  if 
pricked),  there  can  be  no  question,  on  the  other  hand,  that  it 
ought  not  to  be  returned,  but  must  be  dealt  with  in  one  of  the 
ways  to  be  presently  described.  Again,  if  it  is  adherent  to  the 
sac  the  adhesions  when  soft  and  recent  may  be  gently  broken 
down  with  the  finger  and  the  intestine  returned,  unless  such  is 
contra-indicated  from  other  causes  ;  or  when  the  adhesions  are 
old  and  fibrous,  they  may  be  cut  through  and  ligatured,  and  the 
intestine  also  returned  ;  but  when  they  are  thick  and  fleshy,  the 


STRANGULATED    HERNU.  635 

intestine  may  either  be  left  in  the  sac,  as  any  attempt  to  break 
them  down  would  probably  lead  to  the  tearing  of  its  walls,  or  the 
adherent  portions  of  the  sac  may  be  separated  from  the  surround- 
ing tissues  and  returned  with  the  intestine.  In  cases  of  the  above 
kind  the  treatment  is  clear ;  but  when  the  intestine  is  black, 
ecchymosed,  doughy,  sticky,  or  coated  with  lymph,  but  not  actu- 
ally gangrenous,  whilst  the  impression  of  the  stricture  is  well 
marked,  and  the  fluid  in  the  sac  is  of  a  dark  color,  it  becomes  an 
anxious  moment  for  the  Surgeon  to  decide  what  to  do  with  it, 
and  much  must  be  left  to  his  own  judgment  in  each  individual 
case.  As  a  general  rule  it  may  be  said  that  when  only  a  small 
knuckle  of  intestine  is  present,  and  although  black  has  not  lost 
its  shining  color,  and  on  gently  drawing  it  down  there  is  no  sign 
of  ulceration  at  the  seat  of  stricture,  it  should  be  replaced  just 
within  the  ring,  so  that  if  it  subsequently  gives  way  the  faecal  con- 
tents may  escape  externally ;  but  that  when  the  intestine  is  ecchy- 
mosed, doughy,  etc.,  or  it  is  feared  that  ulceration  of  the  mucous 
coat  may  have  already  begun  at  the  seat  of  stricture,  and  especi- 
ally when  a  large  coil  is  present,  it  should  be  left  in  the  sac,  or 
dealt  with  in  one  of  the  ways  to  be  presently  mentioned.  Some 
Surgeons,  however,  if  in  doubt  always  leave  the  intestine  in  the 
sac ;  others  stitch  the  bowel  to  the  parietal  peritoneum,  so  as  to 
leave  the  most  doubtful  part  in  the  centre  of  the  ring  of  sutures. 
If  the  gut  gives  way  the  faeces  will  then  pass  outwards  ;  if  the  in- 
jured part  recovers  the  gut  will  merely  be  left  adherent  by  one 
surface  to  the  inside  of  the  abdominal  wall.  Others  again  estab- 
lish a  lateral  anastomosis  between  the  gut  above  and  below,  and 
should  the  exposed  loop  turn  out  to  be  gangrenous,  remove  it  the 
next  day  and  close  the  ends  of  the  bowel  by  Lembert  sutures. 
When  the  gut  is  clearly  gangrenous  several  courses  are  open  : — 
T.  An  artificial  anus  may  be  made  by  («)  merely  leaving  the 
gangrenous  gut  in  the  sac ;  or  (^)  by  cutting  away  the  gangrenous 
part ;  or  {c)  by  cutting  it  away  and  stitching  the  open  ends  of 
the  intestines  to  the  wound.  A  secondary  operation  will  subse- 
quently be  required  to  close  the  artificial  anus  (p.  641). 

2.  The  gangrenous  part  may  be  cut  away ;  and  the  intestine 
above  and  below  united  and  returned  into  the  abdomen.  When 
this  course  is  selected  some  Surgeons  are  in  favor  of  uniting  the 
gut  in  the  wound  ;  others  through  an  incision  in  the  middle  line 
or  linea  semilunaris.  When  the  m.esentery  is  sufficiently  long  to 
allow  of  the  intestine  being  drawn  down,  the  wound  is  in  my 
opinion  the  better  situation.  When  the  intestine  cannot  be  drawn 
down,  as  in  some  cases  of  femoral  hernia,  then  the  abdominal  in- 
cision is  preferable.  In  inguinal  hernia  the  wound  can  be  readily 
prolonged  into  the  abdominal  cavity.     In  femoral  hernia  to  do 


636  DISEASES   OF   REGIONS. 

this  would  involve  the  division  of  Poupart's  ligament  and  the  sub- 
sequent weakening  of  the  abdominal  wall  in  this  situation.  Which- 
ever method  is  chosen,  sufificient  intestine  should  be  cut  away  to 
ensure  sound  tissue  being  brought  into  contact.  The  peritoneal 
cavity  being  protected  by  aseptic  gauze  packed  round  the  loop  of 
intestine  to  be  dealt  with,  cut  the  gangrenous  portion  completely 
away;  empty  the  distended  portion  above  as  much  as  possible  ; 
clamp  both  the  upper  and  lower  portions  with  rubber  tubing 
passed  through  a  small  incision  in  the  mesentery  to  prevent  further 
faecal  soiling;  irrigate  with  perchloride  of  mercury  ( i  in  2000)  ; 
restore  the  continuity  of  the  gut  by  one  of  the  methods  described 
at  p.  383,  and  replace  the  united  intestine  in  the  abdominal 
cavity.  Remove  the  sac  after  ligature  of  its  neck,  and  close  the 
ring,  and  the  abdominal  wound  in  the  ordinary  way  if  the  opera- 
tion has  been  done  by  the  intra-abdominal  method. 

The  choice  of  establishing  an  artificial  anus,  or  of  excising  the 
gangrenous  portion  and  uniting  the  gut  above  and  below,  will  de- 
pend in  great  measure  on  the  general  condition  of  the  patient, 
and  on  what  assistance  and  appliances  for  an  aseptic  operation 
are  at  hand. 

Should  the  intestine  be  accidentally  wounded  either  in  opening 
the  sac,  or,  as  more  commonly  happens,  in  dividing  the  stricture, 
the  edges  of  the  wound  should  be  united  in  the  way  described  at 
p.  382. 

Tj'eatment  of  oineufum. — When  small  in  amount,  recently  pro- 
truded, and  only  slightly  congested,  the  omentum  should  be 
returned.  When  large  in  amount,  thickened,  inflamed,  or  gan- 
grenous, it  should  be  ligatured,  cut  off,  and  the  stump  returned 
into  the  abdomen.  Aseptic  silk  is  the  best  material  for  ligaturing 
the  omentum.  The  ligature  to  prevent  slipping  should  be  tied 
very  tightly  or  made  to  transfix  the  pedicle,  the  latter,  if  necessary, 
being  gently  jMilled  down  to  ensure  its  being  tied  at  a  healthy 
spot.  When  the  omentum  forms  a  large  mass  it  should  be  care- 
fully unravelled  to  determine  the  absence  of  intestine  in  its  midst, 
and  then  tied  in  separate  ])ortions.  Ligature  of  the  vessels  sep- 
arately is  unsafe,  as  some  may  be  missed,  and  haemorrhage  occur 
into  the  peritoneal  cavity.  The  ligatures  should  be  cut  off  short 
and  returned  with  the  omentum.  They  become  encysted  and 
cause  no  irritation.  If  the  omentum  is  adherent  to  the  intestine 
it  may  be  gently  separated  from  it  or  returned  with  the  intestine. 
If  adherent  to  the  sac  it  may  be  separated  and  returned  or  re- 
moved with  the  latter. 

Division  of  the  stricture  at  the  neck  of  the  sac. — Pass  the  index 
finger  gently  between  the  intestine  and  the  sac,  or  if  the  omentum 
is  spread  out  between  the  intestine  and  the  sac  (forming  the  so- 


STRANGULATED   HERNIA.  637 

called  omental  sac),  between  the  intestine  and  omentum.  The 
stricture  having  been  discovered,  insinuate  the  finger-nail  gently 
under  it,  and  the  intestine  being  held  aside  by  the  other  fingers 
or  by  an  assistant,  pass  the  hernia  knife,  held  with  its  blade  on 
the  flat  and  protected  by  the  pulp  of  the  finger,  beneath  the 
stricture,  turn  its  catting  edge  towards  the  stricture,  and  notch 
the  latter  in  one  or  more  places  by  gently  depressing  the  handle. 
The  direction  in  which  the  notch  should  be  made  will  depend 
upon  the  situation  of  the  hernia  ;  in  extent  it  should  be  as  limited 
as  possible.  The  Surgeon,  as  a  rule,  will  do  better  to  employ  his 
finger  than  the  director,  as  there  is  much  less  risk  of  wounding 
the  intestine  ;  but  if  a  director  is  used  it  should  be  broad  and  flat 

Fig.  305. 
Wormald's  hernia  director. 

(Fig.  305).  If  it  is  found  that  the  stricture  is  not  sufficiently 
divided  to  allow  the  intestine  to  slip  back  on  being  manipulated 
with  the  fingers,  a  second  notch  should  be  made.  But  if  the 
intestine  does  not  then  return  easily,  the  stricture  should  be 
divided  again,  as  no  force  must  be  used. 

Where  the  intestine  is  gangrenous,  some  Surgeons  who  hold 
that  it  is  better  to  leave  the  gangrenous  intestine  in  the  sac 
merely  notch  the  stricture,  disturbing  as  little  as  possible  the  ad- 
hesions that  have  formed  between  the  intestine  and  the  neck  of 
the  sac,  as  it  is  upon  these  cutting  off,  as  they  do,  the  general 
peritoneal  cavity  from  the  gangrenous  gut,  that  the  patient's  safety 
depends.  If  this  course  is  pursued  the  stricture  had  better  be 
divided  from  without  inwards,  so  that  neither  the  finger  nor  the 
director  need  be  pushed  up  from  the  septic  sac  into  the  abdomen. 
If  the  ring  is  thus  treated  the  peritoneal  adhesions  may  be  left 
undisturbed.  The  division  here  is  not  practiced  for  the  purpose 
of  relieving  the  strangulation,  as  the  bowel  is  already  dead  ;  but 
for  the  purpose  of  allowing  the  contents  of  the  bowel  above  the 
gangrenous  part  to  escape  externally. 

Treatment  of  the  sac. — The  next  question  that  arises  is,  what 
should  be  done  with  the  sac?  My  own  practice  has  been,  unless 
otherwise  contraindicated,  to  dissect  up  the  sac,  apply  a  stout 
catgut  hgature  to  its  neck,  and  cut  the  body  of  the  sac  away. 
In  inguinal  hernia  the  ring  may  then  be  brought  together  with 
sutures,  and  the  wound  closed.  \x\  femoral  hernia  the  parts  are 
so  rigid  that  they  are  with  more  difficulty  brought  together.     In 


63  S  DISEASES   OF   REGIONS. 

umbilical  hernia  the  sac  with  the  redundant  integuments  may  bo 
removed,  and  the  wound  united,  with  the  peritoneal  surfaces  in 
contact,  by  deep  and  superficial  sutures.  Some,  however,  still 
prefer  simply  to  leave  the  sac  in  situ,  merely  uniting  the  wound, 
and  applying  a  pad.  The  sac  should  not  be  ligatured  and  cut 
off: — I.  When  the  patient  is  weak  or  collapsed,  and  it  is  desir- 
able to  complete  the  operation  with  as  Uttle  delay  as  possible. 
2.  When  the  intestine  is  in  that  doubtful  condition  that  it  has 
only  been  placed  just  within  the  ring.  3.  When  the  abdomen 
contains  much  serous  fluid,  or  peritonitis  is  present — a  drain-tube 
may  then  be  inserted. 

After-treaimenl. — The  wound  should  be  dressed  antisepticnlly, 
and  a  spica  bandage  firmly  applied.  Half  a  grain  of  morphia 
may  then  be  injected  subcutaneously,  or  a  full  dose  of  opium 
given  by  the  mouth.  Some  Surgeons  keep  the  patient  subse- 
quently under  the  influence  of  the  drug,  in  order  to  place  the  in- 
testine at  rest  till  it  has  had  time  to  recover  from  the  effects  of 
the  inflammation  ;  others  only  employ  it  if  there  is  pain  or  rest- 
lessness. To  further  insure  rest  some  wash  out  the  stomach  with 
the  stomach-pump.  With  the  same  end  in  view  no  nourishment 
should  be  given  by  the  mouth  for  the  first  twelve  or  twenty- four 
hours,  but  ice  in  small  quantities  may  be  sucked  or  teaspoonfuls 
of  hot  water  given  occasionally  to  relieve  thirst  and  check  any 
tendency  to  vomit.  Nutrient  suppositories  or  nutrient  enemata 
after  the  first  twelve  hours  may  be  given  by  the  rectum.  Subse- 
quently milk  in  small  quantities  at  a  time  may  be  taken  by  the 
mouth,  then,  in  addition,  beef  tea ;  but  no  solid  food  should  be 
allowed  till  the  bowels  have  acted.  This  they  should  usually  be 
permitted  to  do  spontaneously,  as  no  harm  will  ensue  should 
they  continue  confined  for  a  week  or  ten  days.  If,  however,  any 
distension  or  uncomfortable  sensations  are  experienced,  an  enema 
of  soap  and  water  may  be  given  and  a  change  of  position  in  bed 
allowed.  If  the  distension  is  great  a  purge  on  the  third  day  may 
sometimes  with  advantage  be  given,  but  such,  however,  in  my 
experience  is  seldom  required. 

Conditious  that  may  give  rise  to  a  continuance  of  the  symptoms 
of  strangulation  after  the  taxis  or  herniotomy. — As  a  rule  the  symp- 
toms of  strangulation  cease  immediately  or  soon  after  the  success- 
ful application  of  the  taxis  or  of  herniotomy.  Should  they  persist 
they  may  de])end  on — i.  The  effect  of  the  anaesthetic.  2.  Paral- 
ysis of  the  muscular  coat  of  the  intestine.  3,  The  presence  of 
another  hernia.  4.  The  displacement  of  the  hernia,  or  reduction 
en  tnasse.  5.  The  gut  becoming  gangrenous  and  giving  way. 
6.  Enteritis  or  peritonitis.  7.  Internal  strangulation  of  the 
intestine. 


STRANGULATED   HERNIA.  639 

If  the  persistence  of  the  symptoms  is  due  to  the  anaesthetic  they 
will  usually  pass  off  in  a  few  hours.  The  vomiting,  moreover,  is 
usually  attended  with  much  retching,  and  is  not  of  that  gushing 
nature  characteristic  of  strangulation  of  the  bowel.  If  due  to 
paralysis  of  the  muscular  coat  of  the  intestine,  the  symptoms  will 
also,  as  a  rule,  gradually  cease  as  the  congestion  passes  off.  Should 
they  not  do  so,  however,  a  careful  search  should  be  made,  if  this 
has  not  already  been  done,  for  another  hernia,  and  if  one  is  dis- 
covered and  appears  strangulated,  it  should  be  explored.  If  no 
other  hernia  exists,  the  continuance  of  the  symptoms  may  be  due 
to  the  hernia  not  having  been  properly  reduced,  to  peritonitis,  to 
the  persistence  of  the  paralysis  of  the  muscular  coat  of  the  gut,  or 
to  internal  strangulation.  If,  therefore,  the  hernia  is  reported  not 
to  have  slipped  back  with  the  usual  gurgle,  or  there  is  some  ful- 
ness felt  about  the  hernial  ring,  the  ring  must  be  cut  down  upon 
and  explored,  or  the  wound,  if  an  operation  has  been  performed, 
opened  up.  It  may  then  be  found  (a)  that  the  hernia  has  been 
reduced  en  masse,  i.  <?.,  that  the  hernia,  along  with  the  sac,  has 
been  forced  between  the  fascia  transversalis  and  the  peritoneum, 
a  condition  most  frequently  met  with  when  the  hernia  is  femoral ; 
{b)  that  the  neck  of  the  sac  has  become  detached,  the  intestine 
remaining  strangulated  ;  (<:)  that  the  posterior  part  of  the  sac  has 
been  rent  and  the  hernia,  still  strangulated  at  the  neck,  forced 
into  the  subserous  connective  tissue;  or  {^d)  that  the  hernia  has 
passed  into  a  pouch  at  the  neck  of  the  sac  instead  of  into  the 
peritoneal  cavity.  Under  any  of  the  above  circumstances  the  sac 
should  be  drawn  down,  the  condition  causing  the  strangulation 
accurately  ascertained,  the  stricture,  wherever  situated,  divided, 
and  the  intestine  returned  into  the  peritoneal  cavity.  Peritonitis 
following  the  reduction  of  a  hernia  may  be  known  by  the  signs 
already  given  at  page  393,  and  should  be  treated  as  there  indi- 
cated. Persistent  paralysis  of  the  muscular  coat,  or  the  existence 
of  internal  strangulation,  may  be  suspected  when  along  with  the 
continuance  of  the  symptoms  of  strangulation  of  the  bowel  the 
signs  of  the  other  conditions  that  may  give  rise  to  such  symptoms 
are  absent.  Should  the  paralysis  not  pass  off  under  the  influence 
of  time,  an  enema,  or  even  a  purgative,  may,  in  some  cases,  be 
useful  to  rouse  the  intestine  to  action,  whilst,  in  rare  instances,  it 
may  become  necessary  to  explore  the  abdomen,  open  the  intestine 
above  the  paralyzed  part,  and  suture  it  to  the  wound  in  the 
parietes.  Internal  strangulation  should  be  treated  as  described 
under  Laparotomy. 

Prognosis. — The  prognosis  in  a  case  of  strangulated  hernia  will 
depend  on  the  length  of  time  the  hernia  has  been  strangulated, 
the  tightness  of  the  stricture,  the  presence  or  absence  of  gangrene 


640  DISEASES   OF  REGIONS. 

or  peritonitis  before  the  operation,  the  amount  of  bruising  in- 
flicted on  the  gut  by  the  taxis,  the  degree  of  exposure  and  manip- 
ulation to  which  the  gut  is  subjected  during  the  operation,  and 
the  general  condition  of  the  patient.  Moreover,  the  prognosis  is 
graver  in  a  small  femoral  hernia,  and  in  a  hernia  which  has  re- 
cently come  down  (inasmxh  as  in  these  the  constriction  is 
usually  tight),  than  in  an  obHque  inguinal  hernia,  or  a  hernia  of 
long  standing,  in  which  the  constriction  is  usually  much  less. 

4.  Obstructed  or  iNCAKCERArED  hernia. — These  terms  are 
generally  applied  synonymou.~,ly  to  an  irreducible  hernia  in  which 
the  protruded  intestine  has  become  obstructed  by  a  collection  of 
undigested  food,  foreign  bodies,  as  fruit-stones,  etc.  The  hernia 
is  most  frequently  met  with  in  old  people,  and,  if  neglected,  is  apt 
to  become  strangulated  or  inflamed.  Symptoms. — As  in  strangu- 
lation, there  may  be  constipation,  colicky  pains,  nausea,  and  per- 
haps vomiting ;  but  the  local  signs  of  strangulation  are  less 
marked.  Thus,  there  may  be  little  or  no  local  pain  and  no  ten- 
sion in  the  sac,  though,  at  times,  it  may  become  distended  and 
larger  than  before  the  incarceration  occurred.  The  impulse  on 
cough  may  still  be  present,  and  hard  faecal  masses  may,  perhaps, 
be  felt.  The  symptoms,  however,  may  gradually  merge  into 
those  of  strangulation,  and  it  is  often  difficult  to  distinguish  mere 
obstruction  from  strangulation,  especially  when  the  former  is  as- 
sociated with  some  inflimmation  of  the  sac.  When  in  doubt  the 
case  should  be  treated  like  one  of  strangulated  hernia.  Treat- 
ment.— A  purgative  enema,  rest  in  the  recumbent  position, 
warmth  or  ice  to  the  part,  and  restriction  of  diet,  should  be  pre- 
scribed. When  there  is  no  vomiting,  a  brisk  purge  is  often  suc- 
cessful, but  before  giving  such  the  Surgeon  should  thoroughly  as- 
sure himself  that  strangulation  does  not  exist.  The  application  of 
the  taxis  is  advised  by  some,  and  doubtless,  in  some  instances, 
the  intestine  may  be  emptied  of  its  contents  by  this  means.  .It 
should  be  remembered,  however,  that  its  use  is  not  unattended 
with  risk. 

5.  Inflamed  hernia. — In  this  condition  the  sac  and  to  some 
extent  its  contents  are  inflamed.  Inflammation  is  most  common 
in  small  irreducible  epiploceles,  and  is  generally  the  result  of  in- 
jury, the  ])ressure  of  a  badly-fitting  truss,  or  of  violent  exercise. 
If  neglected  the  hernia  is  apt  to  pass  into  a  condition  of  strangu- 
lation. 

The  local  symptoms  resemble  those  of  a  strangulated  hernia, 
but  the  impulse  on  cough  is  not  absent,  though  it  may  be  less 
marked  than  in  a  hernia  in  its  ordinary  state,  and  there  is  not  so 
much  tension  in  the  sac  as  when  strangulation  exists.  The  parts 
are   hot,   tender   and    oedematous,  and    there   may   be    feverish 


INFLAMED    HERNIA.  64  T 

symptoms,  vomitin,^  and  constipation.  The  vomit  consists,  how- 
ever, only  of  the  contents  of  the  stomach,  and  is  not  faecal;  the 
constipation  is  seldom  complete,  ar.d  flatus  will  usually  pass. 

Ireatinent. — An  ice-bag  should  be  applied  over  the  hernia,  and 
the  patient  placed  in  the  recumbent  position,  with  the  parts  as 
much  as  possible  relnxed.  The  diet  should  be  restricted  to  small 
quantities  of  milk  and  beef-tea,  and  opium  administered  in  small 
doses.  When  all  signs  of  inflammation  have  subsided,  an  enema 
may  be  given  if  the  bowels  do  not  act  spontaneously.  Should  the 
inflammation  run  into  strangulation,  herniotomy  must  be  per- 
formed ;  whilst,  should  suppuration,  a  very  rare  event,  occur,  the 
pus  must  be  let  out  by  a  free  incision. 

Fcecal fistula  and  artificial  anus  after  operation  for  strartgulated 
hernia. — Faecal  fistula  is  due  to  ulceration  of  the  mucous  mem- 
brane at  the  seat  of  stricture,  and  subsequent  perforation  of  the 
bowel ;  artificial  anus  to  the  gangrene  of  a  considerable  portion  of 
the  strangulated  bowel.  In  both,  adhesions  form  between  the 
serous  coat  of  the  intestine  and  the  parietal  peritoneum,  and  in 
this  way  prevent  the  extravasation  of  f«ces  into  the  general  peri- 
toneal cavity  ;  but  in  the  ftecal  fistula,  the  perforation  of  the  bowel 
being  small,  most  of  the  fsecal  contents  are  passed  per  anum  ; 
whereas,  in  artificial  anus,  the  whole  escape  externally,  and  the  in- 
testine below  shrinks  and  becomes  more  or  less  atrophied.  In 
fsecal  fistula  only  a  fistulous  aperture  discharging  fccces  is  present : 
in  artificial  anus  the  openings  of  the  upper  and  lower  portions  of 
the  intestine  can  generally  be  seen.  The  upper  opening  may  be 
known  by  its  larger  size,  redder  color,  and  by  faeces  issuing  from 
it,  -whilst  at  times  its  mucous  membrane  may  be  prolapsed. 

Treatment. — A  faecal  fistula  will,  as  a  rule,  close  spontaneously, 
and  beyond  keeping  the  parts  clean,  nothing  is  generally  required. 
In  artificial  anus  the  spur-Hke  process  or  eperon  formed  by  the 
projecting  forwards  of  the  posterior  wall  of  the  bowel  by  the  coils 
of  intestine  which  lie  in  the  angle  between  the  upper  and  lower 
portions  of  the  intestine,  may  have  first  to  be  destroyed  by 
Dupuytren's  enterotome,  and  the  lumen  of  the  bowel  being  thus 
restored,  the  artificial  anus  may  be  closed  by  a  plastic  operation, 
or  the  walls  of  the  bowel  united  by  suture.  The  Surgeon,  how- 
ever, should  not  be  in  too  great  haste  to  employ  the  enterotome, 
as  in  the  course  of  time,  in  consequence  of  the  dragging  of  the 
mesentery,  the  spur-like  process  may  become  gradually  retracted, 
and  the  two  portions  of  intestine,  instead  of  lying  parallel,  may  be 
drawn  to  more  or  less  of  an  angle  with  each  other.  In  this  way 
the  lumen  of  the  tube  may  become  gradually  restored,  and  the 
faeces  again  pass  down  the  lower  tube.  A  plastic  operation  will 
then  only  be  required  to  close  the  external  opening,  if  indeed  this 
27* 


642  DISEASES   OF   REGIONS. 

does  not  heal  spontaneously,  as  in  fecal  fistula.  Thus,  a  ring  of 
skin  half  an  inch  wide  should  be  removed  from  around  the  open- 
ing, the  adherent  intestine  separated  from  the  parietes,  the 
mucous  membrane  turned  inwards,  the  raw  intestinal  walls  united 
by  non-penetrating  sutures,  and  the  refreshed  surfaces  of  the 
parietes  brought  into  contact  by  deep  sutures. 

Special  Bernice. 

The  three  most  common  forms  of  hernia  are  : — the  inguinal, 
the  femoral,  and  the  umbilical.  Of  the  rarer  forms  may  be  men- 
tioned the  obturator,  the  ventral,  the  epigastric,  the  diaphragm- 
atic, the  lumbar,  the  ischiatic,  the  perineal,  the  vaginal,  and  the 
rectal. 

Inguinal  hernia  is  one  which  escapes  into  or  through  the  in- 
guinal canal.  Of  this  form  there  are  two  chief  varieties,  the 
oblique  or  external,  and  the  direct  or  internal. 

The  OBLIQUE  or  external  VARIETY  is  so  called  because  it  de- 
scends obliquely  through  the  inguinal  canal,  and  leaves  the  abdo- 
men external  to  the  deep  epigastric  artery.  The  hernia  enters 
the  canal  by  the  internal  abdominal  ring,  and  may  remain  in  the 
canal,  when  it  is  spoken  of  as  incoffifilete,  or,  from  its  resemblance 
to  a  bubo,  as  a  budonocele  ;  or  it  may  pass  through  the  canal  and 
out  of  the  external  abdominal  ring,  when  it  is  said  to  be  complete, 
and  is  then  termed  a  scrotal  or  labial  rupture,  according  as  it  de- 
scends into  the  scrotum  or  labium.  The  coverings  of  an  oblique 
inguinal  hernia  differ  according  as  it  is  complete  or  incomplete, 
and  occurs  in  the  male  or  in  the  female.  When  complete  and  in 
the  male  they  are  from  without  inwards,  t,  skin  ;  2,  superficial  and 
deep  fascia;  3,  intercolumnar  fascia;  4,  cremasteric  fascia;  5,  in- 
fundibuhform  fascia ;  6,  subperitoneal  fat ;  and  7,  peritoneum, 
which  constitutes  the  sac.  In  iht  female  the  cremasteric  fascia  is 
wanting,  otherwise  the  coverings  are  the  same.  In  the  incomplete 
the  only  difference  in  the  coverings  is  that  in  place  of  the  inter- 
columnar fascia  there  is  the  aponeurosis  of  the  external  oblique, 
and  in  place  of  the  cremasteric  fascia  the  lowermost  fibres  of  the 
internal  oblique  and  transversalis  ;  they  are  the  same  in  the  male 
and  female.  The  stricture,  when  the  hernia  is  strangulated,  will 
be  situated  at  the  external  abdominal  ring,  the  internal  abdominal 
ring,  or  anywhere  in  the  inguinal  canal  between  the  two  rings. 

Varieties  of  oblique  inguinal  hernia. — These  will  perhaj)s  be 
better  understood  by  reference  to  the  accompanying  diagrams. 
The  following  are  those  most  commonly  described  : — 

I .  The  common  or  acquiredform  ( the  inguino-scrotal  of  Birkett) . 
The   sac    here    consists    simply  of   a  protrusion  of  periosteum 


INGUINAL   HERNIA. 


643 


through  the  inguinal  canal,  and  the  hernia,  when  complete,  may 
descend  into  the  scrotum  or  labium.  The  testicle  can  always  be 
felt  either  below  or  below  and  behind  the  hernia  (Fig.  306). 

2.  The  conge niial.  In  this  form  the  hernia  descends  into  the 
funicular  process  of  the  peritoneum,  which  has  remained  open, 
and  comes  into  contact  with  the  testicle,  the  funicular  process 
and  tunica  vaginahs,  of  course,  forming  the  sac.     The  testis  is 


Fig.  306. 


Fig.  308. 


Ordinary  acquired 
inguinal  hernia. 
(Bryant's  Sur- 
gery.) 

Fig.  307. 


Congentia 
guinal  hernia. 
(Bryant's  Sur- 
gery.) 


A  congenital  inguinal  hernia. 
The  roll  of  paper  is  that 
originally  placed  in  the  speci- 
men by  Percivall  Pott.  (St. 
Bartholomew's  Hospital  Mu- 
seum.) 


more  or  less  surrounded  by  the  hernia,  instead  of  being  felt  dis- 
tinctly behind  and  below  it,  as  in  the  former  variety  (Figs.  307 
and  308). 

3.  The  hernia  into  the  finiic/dar  process  XQ?,em\At%  the  congeni- 
tal, in  that  the  hernia  descends  into  the  funicular  process  of  the 
tunica  vaginalis,  but  differs  in  that  it  does  not  reach  the  testicle, 
being  cut  off  from  it  by  a  septum  at  the  epididymis.  Should  an 
operation  be  required  in  this  form,  the  testicle  is  not  seen  as  in 
the  congenital. 

The  encysted  congenital  (Fig.  309).  In  this  form  the  funicular 
process  of  the  tunica  vaginahs  is  cut  off  from  the  peritoneal  cavity 


644 


DISEASES   OF   REGIONS. 


Fig.  309. 


Encysted  congeni- 
tal hernia.  (Bry- 
ant's Surgery.) 


by  a  septum  at  the  internal  ring.  The  septum  yields  to  the  pres- 
sure of  the  hernia,  and  becomes  invaginated  before  it  into  the 
unobliterated  funicular  process.  Should  an  operation  be  neces- 
sary, the  anterior  layer  of  the  funicular  process,  and  the  elon- 
gated septum  forming  the  spurious  sac,  will  have 
to  be  cut  through.  Here,  as  in  the  funicular 
variety,  the  hernia  is  not  in  contact  with  the 
testicle. 

5.  The  infantile  hernia  is  one  in  which  the  in- 
testine, enclosed  in  its  sac,  descends  behind  the 
funicular  process  of  the  tunica  vaginalis,  which 
has  remained  unobliterated  but  is  cut   off  by  a 
septum  at  the  internal  abdominal  ring  from  the 
general  peritoneal  cavity.     Should  an  operation 
become   necessary,    three   layers   of    peritoneum 
have  to  be  cut  through,  viz.,  the  anterior  layer  of 
the  unobliterated  funicular  process  of  the  tunica 
vaginalis  ;  the  posterior  layer  of  the  same  ;  and 
finally,  the  true  sac.     The  last  two,  however,  are  generally  inti- 
mately blended,  so  that  there  are  apparently  only  two  layers  to 
cut  through. 

The  direct  or  internal  inguinal  hernia  is  so  called  because 
it  escapes  directly  through  the  external  abdominal  ring,  without 
traversing  the  internal  ring  and  the  whole  length  of  the  canal,  and 
is  situated  intei-nal  to  the  deep  epigastric  artery.  Before  escap- 
ing at  the  external  abdominal  ring,  it  either  passes  through  or 
under  the  conjoined  tendon  of  the  internal  oblique  and  transver- 
salis,  which  is  situated  immediately  behind  the  external  abdominal 
ring;  or  it  protrudes  that  structure  in  front  of  it.  The  coverings 
from  without  inwards  are  :  i,  skin  ;  2,  superficial  and  deep  fascia  ; 
3,  intercolumnar  fascia;  4,  transversalis  fascia;  5,  subperitoneal 
fat ;  and  6,  peritoneum  forming  the  sac.  When  the  conjoined 
tendon  is  protruded  in  front  of  the  hernia,  this,  of  course,  consti- 
tutes an  additional  covering,  and  will  then  be  found  between  the 
intercolumnar  and  transversalis  fasci?e.  It  will  thus  be  seen  that 
the  coverings  of  the  direct  hernia  differ  from  those  of  the  oblique, 
in  the  absence  in  the  former  of  the  cremasteric  fascia,  and  in  the 
substitution  of  the  transversalis  for  the  infundibuliform  fascia. 
The  spermatic  cord  with  its  coverings  from  the  cremasteric  and 
infundibuliform  fascia  lies  to  the  outer  side.  From  what  has  been 
said  above,  it  will  be  seen  that  the  epigastric  artery  is  situated  on 
the  inner  side  of  the  neck  of  the  sac  in  the  oblique  ;  on  the  outer 
sifle  in  the  direct.  The  stricture,  when  the  hernia  is  strangulated, 
will  be  situated  at  the  external  abdominal  ring  or  at  the  aperture 
in  the  conjoined  tendon  through  which  the  hernia  has  passed. 


INGUINAL   HERNIA,  -  645 

Two  varieties  of  direct  inguinal  hernia  are  described  according 
as  the  protrusion  takes  place  internal  or  external  to  the  obliter- 
ated hypogastric  artery,  but  are  not  of  sufficient  importance  to  be 
described  here. 

Signs  and  diagnosis  of  inguinal  her?iia. — There  is  a  swelling  in 
the  inguinal  region  having  the  general  characters  of  hernia  already 
given.  When  incomplete  the  swelling  will  be  in  the  groin,  and  has 
to  be  chiefly  distinguished  from  enlarged  inguinal  glands,  a 
femoral  hernia,  encysted  hydrocele  of  the  cord,  non-descended 
testicle,  abscess  in  the  inguinal  canal,  and  in  rare  instances,  from 
fatty  and  other  tumors  of  the  cord.  When  it  is  complete,  i.  e.,  has 
passed  into  the  scrotum,  the  diagnosis  has  to  be  made  from  hy-' 
drocele  of  the  tunica  vaginalis,  haematocele,  solid  tumors  of  the 
testicle,  and  varicocele,  i.  In  enlarged  glands  the  canal  is  free, 
the  glands  are  felt  in  front  or  it,  and  some  cause  is  present  to 
account  for  their  enlargement.  2.  In  femoral  hernia  the  swelling 
is  external  to  the  spine  of  the  pubes,  the  neck  of  the  hernia  is  be- 
low Poupart's  hgament,  the  inguinal  canal  is  free,  but  the  hernia 
can  be  felt  through  its  front  wall,  and  to  return  it  pressure  must 
be  made  in  a  direction  downwards,  backwards,  and  then  upwards. 
In  inguinal  hernia,  on  the  contrary,  the  swelling  is  internal  to,  or 
covers  the  spine  of  the  pubes  •  the  neck  is  above  Poupart's 
ligament :  the  inguinal  canal  is  occupied  by  it,  and  to  return  it 
pressure  must  be  made  upwards  and  outwards.  3.  In  encysted 
hydrocele  of  the  cord  the  swelling  is  translucent,  tense,  oval,  and 
well-defined.  There  is  no  expansile  impulse  on  cough  ;  and  it 
cannot  be  returned  into  the  abdomen.  4.  In  retained  testicle  that 
organ  is  absent  from  the  scrotum ;  there  is  no  impulse  on  cough  ; 
testicular  sensation  can  be  obtained  by  pressure  on  the  sweUing  ; 
and  it  cannot  be  returned  into  the  abdomen.  If  the  testicle  is 
inflamed  or  the  cord  is  twisted  (see  Torsion  of  the  Spermatic 
Cord),  vomiting  may  be  present,  but  it  has  not  the  gushing  char- 
acter of  the  vomiting  of  hernia,  and  constipation,  if  also  present, 
is  not  complete.  There  may,  however,  be  a  strangulated  hernia 
in  addition  to  an  inflamed  testicle.  The  diagnosis  in  such  a  case 
is  very  difiicult.  If  in  doubt,  an  exploratory  incision  should  be 
made  over  the  tumor.  5.  In  hydrocele  of  the  tunica  vaginalis  the 
tumor  is  translucent,  tense,  and  semi-fluctuating  ;  there  is  absence 
of  impulse  on  coughing,  freedom  of  the  cord,  and  a  history  of  it 
having  begun  at  the  bottom  of  the  scrotum.  In  infants,  however, 
a  hernia  may  be  translucent,  and  in  a  hydrocele  of  the  congenital 
variety,  the  fluid  can  be  pressed  back  into  the  abdomen,  but  it 
does  not  return  with  the  gurgle  or  slip  characteristic  of  a  hernia. 
6.  In  varicocele  the  dilated  veins  feel  like  a  bag  of  worms  in  the 
scrotum,  and  the  impulse  on  cough  has  a  thrill-like  character.     A 


646 


DISEASES   OF   REGIONS. 


varicocele,  like  a  hernia,  is  reduced  on  the  patient  lying  down, 
but  if  the  finger  is  placed  firmly  over  the  ring,  the  veins,  on  the 
patient  rising,  refill  notwithstanding  the  pressure  of  the  finger, 
whereas  a  hernia  would  remain  reduced.  The  indirect  hernia 
cannot  practically  be  distinguished  from  the  direct,  as  the  rings 
get  dragged  opposite  one  another.  The  indirect  is  more  common 
in  the  young,  the  direct  in  the  old. 

Treatment. — What  has  already  been  said  on  this  subject  with 
regard  to  hernia  generally  is  applicable  here,  and  it  need  only  be 
added  that  if  an  operation  is  necessary  the  incision  (Figs.  310  and 


Fig.  310. 


Fig.  311. 


Oblique  inguinal  hernia,  with  line  of  incision.       Direct  inguinal  hernia,  with  line  of  incision. 


311)  should  be  made  downwards  and  inwards,  over  the  long  axis 
of  the  hernia,  beginning  just  above  the  external  abdominal  ring; 
that  the  stricture,  whether  the  hernia  be  direct  or  indirect, 
should  be  divided  directly  up7vards,  so  as  to  avoid  the  epigastric 
artery ;  and  that  when  combined  with  retained  testicle  a  truss 
with  a  -^-shaped  pad  should  be  worn,  if  practicable,  above  the 
testicle.  If  the  truss  causes  the  testicle  to  become  frequently 
inflamed,  the  testicle  had  better  be  removed  (see  retained  testis). 
A  FEMORAL  HERNIA  is  onc  that  cscapcs  into  the  femoral  sheath, 
and  nearly  always  internal  to  the  femoral  vessels,  though  in  very 
exceptional  cases  it  has  been  found  external  to  them.  As  a  rule, 
it  leaves  the  abdomen  at  the  femoral  ring,  and  after  passing 
downwards  through  the  femoral  canal,  emerges  at  the  saphenous 
opening,  and  then  turning  upwards  and  outwards  over  the  ftilci- 
form  process  of  the  fascia  lata,  passes,  should  it  further  increase 
in  size,  over  Poupart's  ligament  on  to  the  aponeurosis  of  the  ex- 
ternal oblique  muscle  of  the  abdomen.     The  neck  of  the  sac  is 


FEMORAL    HERNIA. 


647 


Fig. 


•#C^|^ 


situated  at  \ht  fetrioral  ring  (Fig.  312),  and  is  therefore  bounded 
in  front  by  Poupart's  ligament,  behind  by  the  bone,  internally  by 
the  sharp  wiry  edge  of  Gimbernat's  ligament,  and  externally  by 
the  femoral  vein,  from  which  it  is  .only  separated  by  the  inner- 
most septum  of  the  femoral  sheath.  The  spermatic  cord  is  close 
above  it ;  the  epigastric  artery  passes  a  little  external  to  it ;  but 
there  is  no  structure  of  importance,  as  a  rule,  on  its  inner,  and 
upper  and  inner  side.  The  obturator  artery,  however,  may  be 
given  off  from  the  epigastric  or  external  iliac  artery,  and  encircle 
this  part  of  the  ring  in  its  course  to  the  obturator  foramen  (Fig. 

312).  It  is  then  in  great  danger  of 
being  wounded  in  dividing  the  strict- 
ure. Fortunately,  however,  although 
the  artery  often  rises  in  this  abnormal 
manner,  it  does  not  then,  as  a  rule, 
take  the  above-mentioned  dangerous 
course,  but  passes  along  the  outer 
side  of  the  ring  where  it  is  out  of 
danger.  The  coverings  of  a  femoj-al 
hernia  are — (Fig.  313)  i,  skin;  2, 
superficial  fascia  ;  3,  cribriform  fascia  ; 
4,  anterior  layer  of  the  femoral  sheath, 
called  the  fascia  propria  ;  5,  septum 
crurale  ;  6,  subperitoneal  fat;  and  7, 
peritoneum  forming  the  sac.  The 
fascia  propria  is  often  very  thin,  or  in 
places  absorbed,  so  that  little  more 
than  skin  and  one  or  two  delicate 
layers  of  fascia  cover  the  sac.  But  it  may  be  greatly  thickened, 
especially  over  the  neck  of  the  sac,  where  it  may  form  distinct 
fibrous  bands,  which  go  by  the  name  of  the  deep  crural  arch. 
Femoral  hernia  is  never  congenital ;  and  seldom  occurs  before 
adult  life.  It  is  more  common  in  women  than  in  men.  The 
stricture  when  the  hernia  is  strangulated,  is  at  the  saphenous 
opening,  at  Gimbernat's  ligament,  or  more  rarely  at  the  deep 
crural  arch. 

Signs. — A  femoral  hernia  usually  appears  (Fig.  314)  as  a  tense 
globular  swelling  at  the  upper  and  inner  part  of  the  thigh,  just 
below  Poupart's  ligament,  internal  to  the  femoral  vessels,  and 
external  to  the  spine  of  the  pubes.  It  is  usually  small,  but  may 
sometimes  be  as  large  as  an  orange,  or  even  larger.  It  then  ex- 
tends upwards  and  outwards  over  Poupart's  ligament  towards  the 
iliac  spine,  and  appears  as  an  elongated  soft  and  yielding  swelling 
with  its  long  axis  parallel  to  the  ligament.  Its  neck,  however,  can 
always  be  traced  below  the  ligament  towards  the  femoral  ring. 
The  characteristic  signs  of  hernia  are,  of  course,  present. 


The  obturator  artery  given  oft"  ab- 
normally from  the  epigastric,  and 
running  round  the  upper  and  inner 
side  of  a  femoral  hernia.  iSt.  Bar- 
tholomew's Hospital  Museum.) 


648 


DISEASES    OF    REGIONS. 


The  diagnosis  has  chiefly  to  be  made  from  enlarged  glands, 
varix  of  the  saphenous  vein,  inguinal  hernia,  and  psoas  abscess. 
I.  In  eitlarged glands  there  is  no  impulse  on  cough ;  they  can  be 
raised  from  the  deeper  tissues,  and  there  will  probably  be  some 
evident  cause,  as  a  sore  on  the  heel,  etc.,  to  account  for  them. 
A  small  piece  of  irreducible  omentum,  however,  may  almost  ex- 
actly resemble  an  enlarged  gland  in  the  femoral  canal ;  and  it 
may  be  impossible  to  make  a  diagnosis  without  exploring  the 
ring,  an  operation  which  should  always  be  undertaken  if  symptoms 


Fig.  313. 


Fig.  314. 


//Cjj<^ 


Femoral  hernia.  The  covering.s  dissected  off 
to  show  the  sac.  (Si.  Bartholomew's  Hos- 
pital Museum.) 


Femoral  hernia,  with  line  of  incision. 


of  strangulation  of  the  intestine  are  present.  At  times  there  may 
be  an  enlarged  gland  over  a  hernia.  2. 'In  varix  of  the  saphenous 
vein  the  vein  is  generally  also  varicose  lower  down  the  limb,  and 
the  impulse  on  coughing  has  a  peculiar  thrill-like  character,  and 
extends  also  some  distance  down  the  vein.  When  the  swelling  is 
reduced  by  placing  the  patient  on  her  back,  and  the  ring  is  closed 
by  the  finger,  the  vein  refills  when  she  rises,  whereas  the  hernia 
remains  reduced  as  long  as  the  finger  is  kept  in  position.  3.  In 
inguinal  hernia  the  neck  of  the  sac  is  above  Poupart's  ligament, 
and  inside  or  over  the  spine  of  the  pubes  ;  in  femoral  hernia  the 
neck  is  below  Pou part's  ligament  and  outside  the  spine  of  the 
pubes.  In  inguinal,  the  hernia  goes  back  in  a  direction  upwards, 
outwards  and  backwards  ;  in  femoral,  downwards,  backwards  and 
upwards.  In  inguinal,  the  hernia  occupies  the  inguinal  canal, 
and  may  descend  into  the  scrotum  or  labium ;  in  femoral,  the 
inguinal  canal  is  felt  free  on  passing  the  finger  into  it.  4.  In 
psoas  abscess  the  swelling  is  generally  at  first  external  to  the  fem- 
oral vessels.  There  is  usually  fulness  in  the  iliac  fossa,  and  fluc- 
tuation  can  be  detected  above  and  below  Poupart's  ligament. 


UMBILICAL   HERNIA.  649 

Some  cause  for  the  abscess,  such  as  caries  of  the  spine,  is  gene- 
rally evident. 

'Treatment. — All  that  need  be  mentioned  in  addition  to  what 
has  already  been  said  of  the  treatment  of  hernia  in  general  is — i. 
That  the  femoral  truss  (Fig.  295)  should  have  the  pad  more  ver- 
tically placed,  and  the  button  for  the  strap  should  be  on  the  end 
of  the  spring  and  not  on  the  back  of  the  pad,  as  if  placed  in  the 
latter  situation  it  causes  the  pad  to  rise  up  and  so  allows  the 
hernia  to  escape  beneath  it.  2.  That  in  applying  the  taxis  the 
leg  should  be  flexed,  slightly  adducted,  and  rotated  inwards,  to 
relax  the  falciform  process  of  the  fascia  lata.  3.  That  on  account 
of  the  unyielding  nature  of  the  parts  there  is  but  little  prospect  of 
reducing  the  hernia  under  chloroform  or  by  a  hot  bath.  4.  That 
should  the  hernia  become  strangulated,  ulceration  is  rapidly  pro- 
duced, owing  to  the  pressure  of  the  wiry  edge  of  Gimbernat's  lig- 
ament. Therefore,  if  the  hernia  is  not  returnable  by  moderate 
taxis,  an  operation  should  immediately  be  performed.  5.  That 
the  incision  (Fig.  314)  should  be  made  in  a  vertical  direction 
over  the  inner  side  of  the  neck  of  the  hernia,  the  skin  being  nipped 
up  and  transfixed  to  avoid  injuring  the  sac,  as  the  coverings  are 
often  very  thin.  6.  That  the  stricture  should  be  divided  in  an 
upward  and  inward  direction  through  the  junction  of  Gimbernat's 
with  Hey's  ligament.  If  made  directly  inwards,  the  resulting 
aperture  is  so  large  that  it  is  difficult  subsequently  to  keep  up  the 
hernia  with  a  truss  ;  while  if  made  directly  upwards,  the  spermatic 
cord  and  epigastric  artery,  and  if  outwards,  the  femoral  vein,  are 
endangered.  7.  Several  small  notches  are  preferable  to  a  single 
and  larger  incision,  as  there  is  less  danger  of  wounding  an  ab- 
normal artery  should  one  be  present.  8.  Should  such  an  abnor- 
mal artery  be  wounded  it  must  be  tied  if  possible,  enlarging  the 
incision  if  necessary ;  otherwise  an  attempt  may  be  made  to  twist 
it,  or  a  pressure  forceps  may  be  leit  on. 

Umbilical  hernia  (exomphalos,  or  omphalocele)  is  one  that 
escapes  at  the  umbilicus.  The  sac,  according  to  Mr.  Birkett,  is 
always  an  acquired  one,  and  consists  of  the  parietal  layer  of  peri- 
toneum, and  never  of  a  natural  process  of  peritoneum  like  that  of 
the  funicular  process  in  the  inguinal  region.  In  infancy  the  hernia 
passes  through  the  yet  unclosed  umbilical  ring  ;  in  adults,  through 
an  aperture  in  the  fibres  of  the  linea  alba  near  the  umbilicus.  It 
is  most  often  met  with  in  infants ;  is  rare  in  young  adults  ;  and  is 
more  common,  again,  in  the  old,  especially  in  stout  females.  The 
sac  is  usually  very  thin,  and  frequently  cribriform  or  altogether 
deficient  in  places  ;  whilst  the  contents  usually  consist  of  omen- 
tum and  of  a  small  knuckle  of  intestine,  which  mostly  lies  con- 
cealed in  omentum  at  the  neck  of  the  sac.  The  coverings  are — 
28 


650  DISEASES   OF   REGIONS. 

I,  the  skin ;   2,  the  superficial  and  deep  fascia  with  a  thin  layer  of 
fat  between  them;  3,  the  fascia  transversalis ;  and  4,  the  peri- 
toneum, which  constitutes  the  sac.     They  frequently,  however, 
become  thinned,  adherent  to  one  another, 
F'°-  315-  or  partially  absorbed,  so  that  the  contents 

of  the  hernia  are  merely  covered  with  skin 
and  a  thin  layer  of  fascia  (Fig.  315). 

Symptoms. — In    infancy,    the    hernia, 
which  is  known  by  nurses  as  "  starting  of 
the  navel,"  consists  of  a  protrusion  at  the 
umbilicus,  readily  returning  when  gentle 
pressure  is  applied,  and  when  once  seen 
can   hardly  be    mistaken    for   any  other 
affection.    It  generally  undergoes  a  spon- 
taneous cure.     In  adults  it  forms  a  glob- 
ular, lobulated,   or   sometimes  pyriform 
swelling,  on  the  lower  part  of  which  the 
cicatrix  of  the  navel  is  seen.     It  often 
Umbilical  hernia,  showing  the     ^ttaius  a  large  sizc,  nearly  always  extend- 
attenuated  condition  of  its     ing  as  it  enlarges  downwards  towards  the 
mew"Hospitf/'Mufeum°'°"     pubcs,  and  is  frequently  in  part  or  com- 
pletely irreducible.     It  is  very  liable  to 
become  obstructed  and  less  often  strangulated. 

Treatment. — In  infants  the  hernia  generally  undergoes  a  spon- 
taneous cure,  but  a  pad,  consisting  of  a  piece  of  cork  between 
two  layers  of  lint,  may  be  applied  over  it,  and  fixed  with  strapping 
or  an  india-rubber  bandage.  In  adults  an  umbilical  truss  or 
bandage  is  necessary,  or  when  the  hernia  is  irreducible,  a  hollow 
suj^porting  truss.  W^hen  the  hernia  is  incarcerated,  the  patient 
must  be  placed  at  rest  and  an  enema  administered.  When  strang- 
ulated, an  operation  must  be  ])erformed.  The  incision  should 
then  be  made  vertically  over  the  swelling  in  the  middle  line,  and 
the  sac  opened  with  care,  as  the  coverings  are  often  very  thin, 
and  the  stricture  divided  in  an  upward  direction.  If  omentum 
presents  first,  as  is  usually  the  case,  seatch  must  be  made  for  in- 
testine, and  the  latter  returned  ;  the  omentum  must  then  be  un- 
ravelled, transfixed  with  a  double  ligature,  tied,  cut  off,  and  the 
stump  also  returned.  The  sac  should  then  be  cut  off  with  the 
redundant  skin  and  the  wound  sewn  up  with  deep  sutures  with 
two  peritoneal  surfaces  in  contact.  Radical  cure  is  called  for 
when  a  truss  fails  to  keep  up  the  hernia,  and  strangulation  or  ob- 
struction is  frequently  occurring  (p.  628). 

An  ohtuka'jor  hkknia  is  one  that  escapes  through  the  obtura- 
tor canal,  /.  <?.,  the  aperture  left  in  the  obturator  membrane  for 
the  passage  of  the  obturator  nerve  and  vessels.     'J'he  neck  of  the 


DIAPHRAGMATIC,  OR   PHRENIC   HERNIA.  65  T 

sac  is  bounded  by  the  horizontal  ramus  of  the  pubes  above,  and 
by  the  sharp  edge  of  the  obturator  membrane  elsewhere  ;  whilst 
the  fundus  either  protrudes  the  obturator  externus  in  front  of  it, 
or  passes  above  that  muscle  or  between  its  fibres  and  comes  into 
contact  with  the  pectineus,  giving  rise  to  a  slight  fulness  in  the 
upper  part  of  the  thigh  just  below  Poupart's  ligament,  immediately 
behind  and  internal  to  the  femoral  vessels.  The  coverings,  there- 
fore, are  i,  skin ;  2,  superficial  fascia ;  3,  fascia  lata  ;  4,  pectineus  : 
5,  fascia  over  the  obturator  externus;  6,  obturator  externus 
(sometimes)  ;  7,  pelvic  fascia  ;  8,  subperitoneal  fat;  and,  9,  peri- 
toneum, forming  the  sac,  which  is  always  an  acquired  one.  The 
relation  of  the  obturator  artery  and  nerve  to  the  sac  is  variable. 
The  hernia  is  always  small,  and  generally  consists  of  the  lower 
portion  of  the  ileum,  often  of  only  a  portion  of  the  calibre  of  the 
gut.  Obturator  hemii  is  lare  ;  it  is  most  often  met  with  after  the 
age  of  fifty,  and  then  generally  in  women.  It  has  not  always  been 
diagnosed  during  life,  and  is  often  accompanied  by  other  hernias. 

Symptoms. — The  chief  of  these,  in  addition  to  those  of  strangu- 
lation, which  has  generally  been  present,  are  a  shght  fulness  below 
and  internal  to  the  femoral  vessels,  perhaps  not  perceptible  unless 
the  two  sides  are  compared ;  pain  down  the  inner  side  of  the 
thigh  from  pressure  on  the  obturator  nerve ;  pain  on  pressing 
over  the  obturator  foramen,  and  perhaps  some  increased  resist- 
ance or  swelling  in  this  region  ;  pain  on  rotating  the  thigh  out- 
wards from  the  obturator  muscles,  which  are  then  put  on  the 
stretch,  pressing  on  the  hernia ;  and  pain  and  sweUing  in  the  re- 
gion of  the  obturator  membrane  on  examination  by  the  rectum  or 
vagina.  From  femoral  hernia  it  may  be  known  by  the  neck  be- 
ing below  instead  of  above  the  ramus  of  the  pubes ;  and  by  the 
femoral  ring  being  free. 

Treatment. — The  hernia  has  occasionally  been  reduced  by  the 
taxis,  aided  in  one  instance  by  the  hand  in  the  vagina.  But  this 
method  is  dangerous,  inasmuch  as  the  gut  may  be  injured  or  may 
be  in  a  state  unfit  to  return  into  the  abdomen.  It  is  better,  there- 
fore, to  make  an  incision  similar  to  that  for  femoral  hernia,  but 
slightly  longer,  and  having  divided  the  various  coverings  and 
opened  the  sac,  to  incise  the  stricture  in  a  direction  downwards 
and  inwards,  avoiding  if  possible  the  obturator  artery  and  nerve. 
Where  the  diagnosis  is  doubtful  the  ring  should  be  explored,  either 
in  the  way  described  above  or  through  an  incision  in  the  middle 
line  of  the  abdomen,  the  hernia,  if  one  is  found,  being  in  the 
latter  case  drawn  out  from  the  ring  from  within  the  abdomen, 
after  the  stricture  has  been  cautiously  divided. 

Diaphragmatic,  or  phrenic  hernia,  is  one  that  protrudes 
through  the  diaphragm  into  the  thoracic  cavity.     It  is  very  rare. 


652  DISEASES   OF   REGIONS. 

The  aperture  may  be  due  to  a  congenital  defect,  to  the  enlarge- 
ment of  one  of  the  natural  openings,  or  to  a  wound  or  laceration 
of  the  diaphragm.  The  hernia  usuall}'  occurs  on  the  left  side,  the 
liver  tending  to  prevent  any  protrusion  on  the  right.  There  is  no 
peritoneal  sac,  the  viscus,  which  is  usually  the  stomach  or  trans- 
verse colon,  escaping  into  the  pleural  cavity.  In  the  Museum  of 
St.  Bartholomew's  there  is  a  unique  specimen  of  a  hernia  of  the 
omentum  into  the  pericardium,  the  result  of  a  wound. 

Sympto//is. —  In  some  cases  there  have  been  no  symptoms  ;  in 
other  cases  unnatural  fulness  and  abnormal  resonance  of  the  left 
side  of  the  chest,  with  gurgling  on  auscultation,  excessive  thirst, 
and  signs  of  internal  strangulation,  have  been  observed.  When 
the  result  of  a  wound,  pleurisy  or  peritonitis,  or  both,  have  gener- 
ally soon  supervened  and  carried  off  the  patient.  No  treatment, 
as  far  as  I  know,  had  been  attempted  until  Postempski  recently 
reduced  the  hernia  by  incision  and  sewed  up  the  rupture  in  the 
diaphragm.     This  case  was  successful. 

The  RARER  forms  of  hernia,  viz.,  the  ischiatic,  which  leaves  the 
pelvis  through  the  greater  ischiatic  notch  either  above  or  below 
the  pyriformis ;  the  Iiimhar,\\\i\c\\  escapes  between  the  quadratus 
lumborum  and  external  oblique  ;  \ht  perineal,  which  presents  be- 
tween the  vagina  and  the  rectum  ;  the  pudendal,  which  escapes 
between  the  vagina  and  the  ascending  ramus  of  the  ischium  ;  the 
rectal  and  vaginal,  which  protrude  respectively  into  these  cavities ; 
and  the  ventral,  which  escapes  through  the  linea  alba,  are,  on 
account  of  space,  only  mentioned  to  be  dismissed. 

DISEASES    OF    THE    RECiUM. 

Congenital  mai.forimations. — Imperforate  anus  is  the  only  mal- 
formation that  needs  consideration  here.  Cause. — The  intestinal 
canal  in  early  foetal  life  ends  at  some  little  distance  from  the 
surface  of  the  skin  in  a  blind  pouch  or  cloaca,  which  is  common 
to  it  and  the  genito-urinary  org.ins.  In  the  course  of  develop- 
ment the  cutaneous  tissues  (epiblast)  become  invaginated  towards 
the  cloaca  at  the  spot  which  is  to  be  the  future  anus.  The  in- 
tervening tissues  are  then  gradually  absorbed,  and  a  communica- 
tion is  thus  established  between  the  cloaca  and  the  surface  of  the 
body,  the  intestinal  portion  of  the  cloaca  at  the  same  time  becom- 
ing differentiated  from  the  genito-urinary.  An  arrest  in  the 
above  process  of  development  is  the  cause  of  imperforate  anus. 
Thus  :  I.  Should  no  invagination  of  the  skin  occur,  the  anus  will 
be  entirely  absent.  In  such  a  case  the  intestine  may  terminate 
in  a  blind  pouch  at  a  variable  distance  from  the  surface,  a  thin 
membrane  or  a  considerable  thickness  of  tissue  intervening  be- 


PRURITUS   ANI.  653 

tween  the  skin-surface  and  the  interior  of  the  gut.  At  times  the 
intestine  may  stop  short  of  the  pelvis,  the  rectum  being  then  of 
course  wholly  absent.  2.  Should  invagination  occur,  but  the  in- 
tervening tissues  not  be  absorbed,  an  anus,  to  all  external  appear- 
ances natural,  will  be  present,  but  will  be  found  to  terminate  in  a 
cul-de-sac  a  short  distance  from  the  surface.  Here  again  either  a 
thin  membrane,  or  a  considerable  thickness  of  tissue,  may  inter- 
vene between  the  top  of  the  cul-de-sac  and  the  interior  of  the  gut. 
3.  Should  the  process  by  which  the  intestinal  canal  is  normally  cut 
off  from  the  genito-urinary  portion  of  ihe  cloaca  also  fail,  the  in- 
testine, instead  of  ending  in  a  blind  pouch,  may  communicate 
with  the  bladder,  prostatic  urethra  or  vagina.  In  rare  cases  the 
intestine  may  open  in  some  other  abnormal  situation,  as  the 
perineum  or  groin. 

Treatment. — Where  only  a  thin  iiiembrane  intervenes,  its  divi- 
sion is  all  that  is  necessary  ;  but  where  there  is  no  appearance  of 
an  anus,  or  evidently  a  considerable  thickness  of  tissues  between 
the  gut  and  the  surfice,  a  vertical  incision  should  be  made  in  the 
middle  line  at  the  spot  where  the  anus  should  be  normally 
situated.  If  the  distended  bowel  is  now  seen  or  felt  to  bulge  in 
the  wound,  it  should  be  exposed  with  a  few  touches  of  the  knife, 
and  then  cautiously  opened  by  an  incision  made  in  the  same  di- 
rection as  the  wound.  Should  it  not  be  thus  discovered,  the  dis- 
section must  be  carried  on  cautiously  in  an  upward  and  backward 
direction  for  an  inch  to  an  inch  and  a  half,  of  course  keeping  to 
the  middle  line  and  well  towards  the  sacrum  lest  the  peritoneum 
be  wounded.  If  the  bowel  is  detected,  it  should  be  opened ; 
no  attempt,  however,  should  be  made  to  bring  it  down,  but  a 
bougie  passed  daily  to  prevent  the  wound  re  contracting.  If  not 
found  in  this  way,  the  colon  may  be  opened  in  the  left  loin  {lum- 
bar colatojny)  or  in  the  left  groin  {inguinal  c ototomy).  Opinions 
differ  as  to  which  of  these  operations  is  preferable.  There  are 
advantages  and  disadvantages  attending  each  which  cannot  be 
here  discussed.  On  the  whole  the  operation  in  the  groin  in  my 
opinion  is  the  best. 

Mayo  Robson  advises  us  to  continue  the  dissection  in  the  peri- 
neum, open  the  peritoneum,  seek  the  end  of  the  gut,  pull  it 
down,  and  fix  it  to  the  skm.  The  only  objection  1  can  see  to 
this  method  is  the  extreme  sraallness  of  the  parts  in  the  new-born 
infant. 

Pruritus  ani,  or  itching  about  the  anus,  though  often  dependent 
upon  constipation,  ascarides,  pediculi,  eczema  marginatum,  con- 
dylomata, piles,  or  other  diseases  of  the  rectum,  sometimes  occurs 
without  any  very  evident  cause,  and  has  then  been  attributed  to 
disordered  digestion  and  gouty  habit.     Symptoms, — The  itching 


654  DISEASES   OF   REGIONS. 

is  often  intolerable,  and  is  usually  worse  soon  after  the  patient 
gets  warm  in  bed.  There  may  be  some  slight  cracks,  a  little 
eczema  from  the  scratching,  or  a  moist  and  reddened  condition 
of  the  skin,  but  occasionally  there  is  nothing  to  be  seen.  Treat- 
ment.— The  c:uise  if  possible  should  be  removed.  Where  none  is 
very  evident,  the  general  health  must  be  attended  to,  the  parts 
kept  scrupulously  clean,  and  an  ointment  or  lotion  of  perchloride 
of  mercury,  boracic  acid,  nitrate  of  silver,  cocaine,  etc.,  apphed. 
I  have  found  lactate  of  lead,  made  by  pouring  lead  lotion  into 
milk,  to  have  a  very  beneficial  effect. 

Fissure  of  the  rectum  is  a  small  painful  crack  or  ulcer,  usually 
situated  just  within  the  anus,  and  seldom  involving  more  than  the 
skin  or  mucous  membrane.  Causes. — Almost  always  constipa- 
tion;  sometimes  neglect  of  local  cleanliness  or  other  source  of 
irritation.  The  passage  of  an  unusually  hard  motion  is  often  the 
immediate  exciting  cause.  When  the  ulcer  is  once  thoroughly 
established,  healing  is  prevented  by  the  action  of  the  sphincter 
and  the  irritation  of  its  surface  during  the  pnssage  of  a  motion. 
Sy»ipto7ns. — The  chief  of  these  is  pain,  the  result  of  spasm  of  the 
sphincter.  It  is  often  very  severe,  and  occurs  during  and  after 
defaecation.  It  may  last  for  a  few  minutes  or  longer,  even  to 
several  hours,  and  then  ceases  till  the  next  motion.  The  pain 
may  not  only  be  felt  in  the  anus,  but  may  be  reflected  down  the 
thighs  or  to  other  parts,  as  the  uterus,  vagina,  or  testicle.  The 
motions  are  often  slightly  streaked  with  blood,  sometimes  with 
pus.  On  examination,  the  sphincters  are  found  spasmodically 
contracted.  On  gently  everting  the  margins  of  the  anus  the  end 
of  the  ulcer  will  be  discovered  usually  at  the  posterior  part,  a 
small  external  pile  or  oedematous  fold  of  skin  which  is  gener- 
ally present  then  serving  as  guide  to  it.  The  passage  of  the 
finger  is  attended  with  great  pain.  Treatment. — In  slight  cases, 
the  use  of  laxatives  and  the  application  of  astringent  lotions  or 
sedative  ointments  before  and  after  defaecation  may  be  suffi- 
cient. If  these  fail,  the  sphincter  may  be  forcibly  dilated,  or 
the  ulcer  divided  together  with  half  or  more  of  the  external 
sphincter  by  drawing  a  straight  bistoury  longitudinally  through 
the  base  of  the  ulcer.  The  bowels  should  then  be  kept  con- 
fined for  four  or  five  days,  and  the  motions  afterwards  kept  soft 
for  a  fortnight  or  longer.  Or  the  sphincter  may  be  divided  sub- 
cutaneously  by  passing  a  tenotomy  knife  beneath  it  through  the 
mucous  membrane  and  cutting  outwards  towards  the  skin.  •  Ball 
treats  these  cases  by  cutting  off  the  small  pile  at  the  end  of  the 
fissure.  This  little  operation,  antl  that  of  subcutancoiis  division 
of  the  sphincter,  may  be  done  without  ])ain  by  painting  the 
mucous  membrane  with  cocaine  or  spraying  it  with  chloride  of 


PROLAPSUS    RECTI.  655 

ethyl,  and  does  not  necessitate  the  patient's  lying  up  for  more 
than  two  or  three  days. 

Prolapsus  recti  is  the  protrusion  of  the  mucous  membrane  of 
the  lower  part  of  the  rectum,  and  more  rarely  of  the  muscular  coat 
as  well,  through  the  anus.  It  is  most  common  in  children,  but 
may  occur  at  any  age.  The  causes  are  either  a  relaxed  state  of 
the  sphincter  induced  by  general  weakness,  residence  in  hot 
climates,  etc.,  or  excessive  straining  due  to  stricture  of  the  urethra, 
phimosis,  stone,  ascarides,  constipation,  piles,  or  polypus.  Signs 
and  diagnosis. — It  commonly  appears  as  an  irregular  ring  of 
mucous  membrane,  or  when  much  is  protruded,  as  a  cylindrical 
elongated  swelling.  When  recent,  it  has  the  color  of  healthy 
mucous  membrane,  but  if  not  soon  reduced  it  may  become  livid 
and  congested,  in  consequence  of  constriction  of  the  blood-vessels 
by  the  sphincter.  The  strangulation  may  proceed  to  such  an  ex- 
tent that  the  prolapsed  portion  may  undergo  mortification  and 
slough  away.  In  old  standing  cases  it  becomes  indurated  and 
leathery  from  exposure.  It  may  be  diagnosed  from  polypus  by 
the  presence  of  a  central  aperture,  and  from  intussusception  by  the 
mucous  membrane  being  continuous  with  that  of  the  sphincter. 
In  intussusception  a  sulcus  exists  between  the  protruded  part  of 
the  bowel  and  the  sphincter. 

Treatment. — Should  the  bowel  be  protruded  or  strangulated,  an 
attempt  should  be  made  to  reduce  it.  If  it  has  only  been  pro- 
lapsed a  short  time,  this  is  easily  accomplished  by  gentle  pressure, 
the  parts  having  been  well  smeared  with  vaseline  and  the  buttocks 
raised.  When  of  longer  standing,  firm  pressure  must  be  exercised 
on  it  for  ten  minutes  or  so,  or  the  finger  may  be  introduced  into 
the  orifice  and  the  bowel  pressed  back.  If  reduction  fails  and 
the  part  is  much  inflamed,  an  ice-bag  may  be  applied,  and  another 
attempt  subsequently  made,  when,  if  still  unsuccessful,  nothing 
remains  but  to  allow  the  protruded  part  to  slough  off  or  to  excise 
it.  If  the  muscular  coat  protrudes,  no  operation  should  be  done 
lest  the  peritoneum  be  wounded.  Having  reduced  the  bowel,  the 
cause  of  the  prolapse  should,  if  possible,  be  removed,  and  to  pre- 
vent a  recurrence  the  nates  may  be  strapped  together,  or  a  pad 
and  T-bandage  worn,  and  the  motions  passed  at  bed-time  instead 
of  in  the  morning,  the  patient  lying  on  his  side  or  back  during 
defsecation.  Astringent  lotions  or  ointments  of  sulphate  of  iron, 
galls,  or  tannin  should  be  applied,  or  the  mucous  membrane 
painted  with  nitrate  of  silver,  whilst  any  pendulous  folds  of  skin 
may  be  snipped  off,  so  as  to  cause  some  amount  of  contraction  of 
the  anus.  In  the  meanwhile,  the  motions  should  be  rendered 
soft  with  gentle  laxatives.  Should  these  means,  after  being  well 
persevered  in,  fail,  a  more  serious  operation  may  become  neces- 


656  DISEASES    OF    REGIONS. 

sary.  Thus,  portions  of  the  mucous  membrane  may  be  removed 
by  ligature ;  or  the  galvano-cautery  may  be  applied  in  two  or 
three  situations,  so  as  to  produce  Hnes  of  burns  in  the  long  axis  of 
the  bowel,  and  thus  cause  the  mucous  membrane  to  adhere  to  the 
muscular  coat  by  inflammation. 

H/E.MORRHOiDS  OR  PILES  are  swellings  inside  or  around  the  mar- 
gin of  the  anus,  the  result  of  a  dilated  or  varicose  state  of  the 
blood-vessels. 

Causes. — The  peculiar  anatomical  arrangement  of  the  hsemor- 
rhoidal  veins  ;  the  absence  of  valves  in  them  and  in  the  veins 
through  which  they  communicate  with  the  portal  vein,  whereby 
they  have  to  sustain  the  whole  weight  of  the  column  of  portal 
blood  ;  and  their  situation  between  the  muscular  and  mucous  coats 
of  the  rectum,  so  that  they  receive  but  little  support  during  de- 
fsecation,  render  them  exceedingly  liable  to  become  dilated  or 
varicose.  Anything,  therefore,  that  tends  to  congest  the  portal 
system,  and  hence  obstruct  the  return  of  venous  blood  from  the 
hemorrhoidal  veins,  such  as  high  living,  habitual  constipation, 
cirrhosis  of  the  liver,  heart-disease,  etc.,  may  be  looked  upon  as  a 
predisposing  cause  ;  whilst  anything  determining  local  congestion 
of  the  part,  such  as  straining  at  stool  or  to  pass  water  in  cases  of 
enlarged  prostate  or  stricture  of  the  urethra ;  the  pressure  of  the 
gravid  uterus,  distended  colon,  or  ovarian  or  other  pelvic  tumor; 
stricture  of  the  rectum,  and  the  abuse  of  aloetic  purgatives,  may 
be  regarded  as  an  exciting  cause. 

Pathology. — Haemorrhoids  consist  at  first  of  little  more  than 
dilated  veins,  but  after  they  have  existed  some  time  the  blood  in 
their  interior  may  clot,  the  vein-walls  hypertrophy,  and  the  con- 
nective tissue  of  the  dilated  vein  become  infiltrated  and  thickened. 
If  a  pile  is  now  cut  into,  it  presents  a  spongy  vascular  structure, 
and  there  is  often  a  small  artery  in  its  centre.  Piles  may  be  situ- 
ated external  to  the  sphincter,  and  are  then  covered  with  skin 
{external  or  blind  piles)  ;  or  within  the  sphincter,  when  they  are 
covered  with  mucous  membrane  {internal or  bleeding  piles).  In 
many  instances,  however,  they  may  be  covered  in  part  with  skin, 
and  in  part  with  mucous  membrane  {mixed  piles).  An  oede- 
rnatous  and  swollen  condition  of  the  muco-cutaneous  folds  and 
hypertrophied  flaps  of  skin  about  the  margin  of  the  anus,  although 
not  produced  by  dilatation  of  the  veins,  is  also  generally  spoken 
of  as  piles.  External  piles  occur  as  soft,  globular,  pinkish-blue 
swellings,  or  as  moderately  firm  fleshy  tumors,  or  as  little  more 
than  loose  hypertrophied  folds  of  skin.  Internal  piles  also  pre- 
sent various  forms.  They  may  consist  of  small  hsemonhoidal 
veins,  dilated  and  varicose,  giving  the  mucous  membrane  a  dark 
pur[j]ish  color,  and  rendering  it  liable  to  become  prolapsed  dur- 


HEMORRHOIDS. 


657 


Fig.  316. 


ing  defaection  ;  or  they  may  form  either  slightly  raised,  flattish 
and  oblong  elevations,  or  distinctly  globular  pedunculated  swell- 
ings (Fig.  316).  They  may  appear  very  vascular  from  the 
congestion  of  the  mucous  membrane  covering  them,  and  then 
constitute  the  bleeding  pile  ;  or  they  may  be  firm  and  fleshy  and 
of  a  reddish-brown  color  from  the  thickening  of  the  mucous  mem- 
brane, and  then  do  not  readily  bleed.  The  haemorrhage  is  usually 
arterial,  and  comes  from  the  small  arteries  in  the  mucous  mem- 
brane. Piles,  whether  external  or  internal,  are  at  times  liable  to 
become  inflamed  and  slough. 

Syjnptoms. — External  piles,  beyond  causing  some  amount  of 
itching  and  unpleasant  sensations  about  the  anus,  may  give  rise 
to  no  symptoms  unless  irritated  or  inflamed.  They  are  then 
often  a  source  of  much  distress.  The  pile  becomes  swollen  and 
painful,  the  pain  being  reflected  to  the  surrounding  parts  and  in- 
creased on  sitting,  standing,  and 
walking.  The  acute  symptoms 
usually  subside  in  a  few  days,  but 
often  leave  the  parts  thickened 
and  irritable,  and  are  liable  to  re- 
cur from  time  to  time.  Internal 
piles  are  productive  of  more 
trouble,  the  chief  symptoms  to 
which  they  give  rise  being  haem- 
orrhage, and  irritation  and  pain 
consequent  on  their  protrusion 
and  constriction  by  the  sphincter, 
or  as  the  result  of  their  becoming 
inflamed ;  whilst  the  haemorrhage,  when  severe,  may  be  pro- 
ductive of  anaemia  and  all  its  attendant  constitutional  symptoms. 
The  amount  of  haemorrhage  may  vary  from  a  few  drops — a  mere 
streaking  of  the  motions  with  blood — to  several  ounces. 

When  first  noticed,  the  protrusion  of  the  piles  occurs  only 
during  defecation  ;  and  although  they  may  at  first  go  back  spon- 
taneously, they  often  require  replacement  by  the  finger,  as  other- 
wise they  are  apt  to  become  strangulated  by  the  sphincter  and 
irritated  or  inflamed  from  the  chafing  of  the  clothes.  Later  the 
sphincter  becomes  dilated,  and  they  may  protrude  at  times  other 
than  during  defaecation,  and  in  long-standing  cases  the  mucous 
membrane  becomes  permanently  prolapsed,  and  the  pile  remains 
constantly  protruded.  External  piles  then  generally  form  in  ad- 
dition to  the  internal,  whilst  the  mucus  exuded  from  the  parts  is 
a  constant  source  of  annoyance.  The  constitutional  symptoms  to 
which  the  loss  of  blood  and  the  pain  and  irritation  may  give  rise 
are    pallor,   palpitation    brealhlessness,    fainting   and   headache. 


Internal  piles.     (St.  Bartholomew's  Hos- 
pital Museum.) 


6s  8  DISEASES   OF   REGIONS. 

From  the  reflex  character  of  the  pam  the  patient  may  refer  the 
symptoms  to  other  organs,  as  the  testicle,  bladder,  kidneys  or 
uterus. 

Diag?wsis. — Exiernai  piles  may  be  readily  diagnosed  from 
condylomata,  polypi,  and  carcinoma,  by  the  characters  already 
given.  Internal  piles  may  be  suspected  from  the  above-mentioned 
symptoms,  and  if  not  protruded  they  may  generally  be  brought 
into  view  by  asking  the  patient  to  bear  down,  as  if  to  defecate, 
whilst  the  Surgeon  makes  gentle  traction  on  the  margin  of  the 
anus.  If  this  does  not  succeed  and  the  bowel  is  loaded,  an  enema 
should  first  be  given.  Examination  with  the  finger,  unless  the 
Surgeon  has  had  some  experience,  fails  to  detect  the  pile,  as 
when  neither  irritated,  inflamed,  nor  protruded,  it  is  soft  and 
flaccid,  like  the  rest  of  the  mucous  membrane. 

The  treatment  of  piles  may  be  divided  into  the  palliative  and 
the  radical. 

The  palliative  treatment  consists  in  employing  such  means  as 
are  calculated  to  reUeve  the  congestion  of  the  hasmorrhoidal 
veins.  Thus  constipation  must  be  combated  by  the  use  of  such 
laxatives  as  the  confection  of  senna,  compound  liquorice  powder, 
the  liquid  extract  or  cordial  of  cascara  sagrada,  or  Pullna  or 
Friedrichshall  waters ;  whilst  strong  purgatives,  especially  aloes, 
high  living,  and  alcoholic  stimulants,  should  be  avoided,  and  the 
secretions  of  the  liver  promoted  by  exercise.  Where  there  is 
haemorrhage,  the  tincture  of  hamamelis  or  of  steel  will  be  found 
very  useful.  Locally,  the  parts  should  be  kept  scrupulously  clean, 
and  astringed  by  such  applications  as  the  liquid  extract  of  hama- 
melis, the  compound  ointment  of  galls,  or  lotions  of  sulphate  of 
iron,  acetate  of  lead,  or  tannic  acid,  passed  through  the  sphincter  ; 
or  by  injections  of  ice-cold  water,  to  which  tincture  of  hamamelis 
may  be  added.  When  the  piles  are  inflamed,  the  patient  should 
rest  in  bed  with  the  buttocks  raised,  an  ice-bag  or  hot  poultice 
should  be  applied,  and  a  morphia  suppository  introduced  into 
the  rectum.  Where  coagulation  has  taken  place,  free  incision 
into  the  pile  and  turning  out  the  clots  will  give  relief. 

The  radical  treatment  consists  in  removing  the  piles,  but  should 
only  be  resorted  to  when  palliative  measures  after  a  fair  trial  have 
failed,  or  when  the  piles  are  more  or  less  constantly  down.  It 
need  hardly  he  said  that  no  operation  should  be  performed  when 
they  are  merely  symptomatic  of  some  more  serious  disease,  as 
stricture  or  cancer  of  the  rectum,  enlargement  of  the  prostate,  or 
disease  of  the  uterus,  bladder,  or  liver,  or  are  the  result  of  preg- 
nancy. The  method  of  removing  the^  piles  differs  according  as 
they  are  external  or  interna!. 

External  piles  may  be  simply  snipped  off  with  the  scissors,  care 


HEMORRHOIDS.  659 

being  taken,  however,  not  to  remove  too  much  of  the  integument, 
lest  troublesome  contraction  of  the  anal  orifice  should  ensue. 

Internal  piles  may  be  treated  by  ligature,  the  clamp  and  cau- 
tery, crushing,  injections  with  carbolic  acid,  excision,  or  the  ap- 
plication of  nitric  acid.  Whatever  method  is  employed  a  purga- 
tive should  be  given  the  day  before,  and  the  rectum  cleared  on 
the  morning  of  the  operation  by  enema  ;  and  after  the  patient  is 
under  the  influence  of  the  anaesthetic,  the  anus  should  be  forcibly 
dilated  to  bring  the  parts  well  into  view,  and  to  paralyze  the 
sphincter. 

If  the  ligature  is  employed,  the  most  prominent  pile  should  be 
seized  with  the  pile -forceps  or  pile-hook,  and  the  mucous  mem- 
brane in.cised  with  the  pile-scissors  at  its  junction  with  the  skin,  so 
as  to  detach  the  pile  and  mucous  membrane  from  the  anal  mar- 
gin. A  carbolized  silk  ligature  should  then  be  placed  in  the 
groove  thus  formed,  and  tied  tightly  around  the  undetached  base 
of  the  pile,  taking  care  to  include  as  much  of  the  mucous  mem- 
brane above  the  pile  as  possible.  The  greater  part  of  the  pile 
having  been  excised,  the  ends  of  the  ligature  are  cut  off  and  the 
stump  of  the  pile  returned  after  the  others  have  been  treated  in  a 
similar  way.  The  parts  should  be  thoroughly  dusted  v/ith  iodo- 
form, a  morphia  suppository  passed  into  the  anus,  and  a  large  pad 
of  iodoform  wool  applied  and  secured  in  situ  by  a  T-bandage. 
The  bowels  should  be  kept  confined  for  four  or  five  days  by  sm.all 
doses  of  opium  combined  with  tincture  of  catechu,  and  then 
opened  by  castor  oil  or  an  enema  of  olive  oil.  Should  retention 
of  urine  occur,  as  is  very  common  after  operations  on  the  rectum, 
it  should  be  reheved  by  passing  a  soft  catheter.  The  hgatures 
generally  come  away  about  the  ninth  to  the  eleventh  day. 

Clamp  and  cautery. — A  pile  having  been  seized  with  the  for- 
ceps, the  clamp  is  apphed  to  its  base,  the  pile  shaved  off,  and  the 
raw  surface  cauterized. 

\{  crushing  is  employed,  the  pile  is  drawn  into  the  crusher, 
which  is  then  screwed  tightly  home,  the  pile  cut  off,  and  the 
crusher  removed  after  a  minute  or  two. 

Excision  has  of  late  been  extensively  employed  by  some  sur- 
geons. It  consists  in  dissecting  away  the  piles,  tying  any  arteries 
that  bleed,  and  bringing  down  the  mucous  membrane  and  secur- 
ing it  by  suture  to  the  anal  margin. 

Injections  of  carbolic  acid. — The  strength  usually  employed  is 
half  a  drachm  of  the  acid  to  a  drachm  each  of  glycerine  and 
water,  four  or  five  minims  being  thrown  into  the  centre  of  the  pile 
by  a  hypodermic  syringe.  The  process  has  to  be  repeated  several 
times,  and  takes  some  weeks  to  effect  a  cure. 

Nitric  acid  is  a  useful  and  efficient  application  for  the  sessile 


66o  DISEASES   OF   REGIONS. 

vascular  pile,  and  should  be  applied  with  a  glass  rod  through  a 
speculum,  and  any  excess  of  acid  removed  by  a  weak  alkaline 
lotion. 

An  iscHio-RECTAL  ABSCESS  (Fig.  3i7),is  one  that  forms  in  the 
loose  cellular  tissue  in  the  ischio-rectal  fossa,  and  should  be  dis- 
tinguished on  the  one  hand  from  the  small  abscesses  which  may 
occur  round  the  margin  of  the  anus  in  the  cutaneous  folds  {peri- 
anal) ,  and  on  the  other  hand  from  the  abscesses  which  may  form 
between  the  mucous  and  muscular  coats  of  the  rectum  or  round 
the  gut  in  the  pelvic  cellular  tissue.  The  came  of  ischio-rectal 
abscess  is  inflammation  round  the  rectum  {periproctitis).  The 
inflammation  may  be  due  to  perforation  of  the  mucous  membrane 
by  a  fish-bone  or  other  foreign  body,  followed  by  ulceration  and 
the  escape  of  faeces  into  the  ischio-rectal  fossa ;  or  it  may  be  due 
to  injury  from  without,  as  a  kick  or  blow.  In  tubercular  subjects 
abscess  is  common  from  very  slight  causes,  and  is  probably  then 
the  result  of  the  breaking  down'of  a  local  deposit  of  tubercle. 
The  symptoms  vary  according  as  the  abscess  is  acute  or  chronic. 
The  acute  begins  with  pain,  which  soon  becomes  throbbing,  and 
is  followed  by  swelling  and  redness  on  one  side  of  the  anus,  and 

Fig.  320. 


Complete  Blind  internal  Blind  external 

fistula.  fistula.  fistula. 

later  by  fluctuation.  In  the  chronic  the  symptoms  may  be  so 
slight  as  to  escape  notice  till  the  alvscess  bursts  into  the  bowel 
and  the  pus  escapes  by  the  anus.  JVeatment. — An  early  incision 
should  be  made  in  order  to  prevent,  if  possible,  the  abscess  break- 
ing into  the  bov/el  and  a  fistula  resulting.  The  incision  should 
be  free  and  of  a  T-shape,  to  secure  a  free  vent  for  the  discharge 
and  promote  the  healing  of  the  abscess  from  the  bottom,  lest  the 
abscess  cavity,  as  is  very  frequently  the  case,  from  the  constant 
action  of  the  sphincter,  degenerate  into  a  fistula  (Figs.  318,  319 
and  320). 

Fistula  in  ano  is  a  fistulous  track  by  the  side  of  the  rectum. 
Three  forms  are  described  :  i.  The  complete  ( l*'ig.  318),  in  which 
the  fistula  opens  internally  into  the  rectum,  and  externally  on  to 
the  skin  ;  2.  The  blind  external  {  V\g.  320),  in  which  it  only  opens 
on  to  the  skin  ;  and  3.  The  blind  internal  ( l''ig.  319),  in  which  it 
only  opens  into  the  bowel. 


FISTULA   IN   ANO.  66 1 

The  complete  (Fig.  318)  is  by  far  the  most  common  form.  It 
generally  extends  obliquely  upwards  on  one  side  of  the  anus  and 
opens  into  the  bowel  between  the  external  and  internal  sphinc- 
ters, or  it  may  take  a  curved  course  around  the  bowel  and  then 
open  into  it  {the  horseshoe  fistula).  Frequently  it  extends  up  be- 
yond the  internal  opening  by  the  side  of  the  rectum  in  the  form 
of  a  cul-de-sac  ;  or  it  may,  though  very  rarely,  open  into  the  bowel 
several  inches  above  the  anus.  In  rare  instances  there  may  be 
two  internal  openings.  Secondary  fistulae  branching  off  from  the 
main  fistula  are  often  found  burrowing  beneath  the  skin  of  the 
perineum  and  buttock.  The  external  opening,  however,  is  usu- 
ally about  half  an  inch  from  the  anus  ;  but  it  may  be  a  greater 
distance  from  it ;  or  close  to  it,  and  then,  perhaps,  hidden  by  the 
loose  folds  of  skin.  It  may  be  little  more  than  a  minute  hole  ex- 
uding a  slight  moisture  ;  or  it  may  be  encircled  by  a  ring  of  gran- 
ulations, and  the  skin  in  its  neighborhood  may  be  re<J  and  brawny. 
The  fistulous  track  itself  will  "generally  be  found  lined  with  a 
smooth  shining  membrane,  and  its  walls  indurated  when  it  has 
existed  some  time. 

Causes. — A  fistula  is  generally  the  result  either  of  the  bursting 
of  an  ischio-rectal  abscess  into  the  bowel,  or  on  to  the  skin,  or  in 
both  directions ;  or  of  ulceration  or  perforation  of  the  mucous 
membrane  and  the  extension  of  the  ulcerative  track  downwards 
towards  the  skin,  which  it  may  or  may  not  penetrate.  It  is  often 
seen  in  phthisical  subjects,  and  occurs  as  a  complication  of  can- 
cerous and  other  strictures  of  the  rectum.  The  two  chief  reasons 
why  the  fistula  does  not  close  are  the  constant  movements  of  the 
sphincter  and  the  escape  of  faecal  matter  into  it. 

Symptoms. — Uneasiness,  pain  or  tenderness  of  the  parts,  espec- 
ially on  defsecation  and  movement ;  more  or  less  constant  dis- 
charge of  pus  or  purulent  fluid  from  the  external  opening  ;  escape 
of  fffices  where  the  fistula  is  complete,  or  a  discharge  of  pus  from 
the  bowel  if  the  fistula  is  of  the  blind  internal  variety ;  mental 
worry,  anxiety  and  depression ;  at  times  exacerbation  of  the  in- 
flammation with  pain  and  increased  discharge ;  and  probably  the 
history  of  a  previous  abscess  having  formed  in  the  ischio-rectal 
fossa. 

Diagnosis. — In  the  complete  variety  (Fig.  318)  the  diagnosis  is 
readily  made  by  passing  a  probe  up  the  fistula  into  the  bowel,  and 
by  feeling  the  internal  opening  (which  has  sometimes  the  form  of 
a  small  depression  in  the  centre  of  a  slight  papilla-like  eminence) 
with  the  finger  in  the  rectum.  In  the  blind  interiial  (Fig.  319)  a 
soft  spot  in  the  centre  of  an  indurated  portion  of  the  tissues  by 
the  side  of  the  anus  wiU  be  felt,  and  probably  an  indurated  track 
will  be  detected  leading  from  this  towards  the  bowel.    The  inter- 


662  DISEASES   OF   REGIONS. 

nal  opening,  which  has  the  characters  given  above,  will  be  discov- 
ered just  within  the  anus  on  passing  the  finger  into  the  rectum. 
Into  this  opening  a  bent  probe  may  be  passed,  and  its  end  made 
to  project  under  the  soft  spot  on  the  skin-surface.  In  the  blind 
external  (Fig.  320)  the  probe  cannot  be  made  to  enter  the  bowel 
on  being  passed  up  the  fistula,  and  no  internal  opening  can  be 
felt  in  the  rectum  by  the  finger.  In  all  cases  the  rectum  should 
be  carefully  examined  to  exclude  stricture  or  cancerous  disease. 
From  urinary  fistulae  tracking  down  towards  the  anus  a  fistula  in 
ano  is  readily  distinguished  by  the  characters  given  above,  and  by 
the  absence  of  urethral  and  bladder  trouble,  and  by  no  urine 
escaping  through  the  fistula. 

Treatment. — Although  in  exceptional  instances  fistulae  have 
closed  spontaneously,  an  operation,  as  a  rule,  is  required.  Before 
operating  for  fistula  the  chest  ought  always  to  be  examined,  since, 
should  tubercle  in  the  lungs  be  discovered,  no  operation  should 
be  done  unless  the  tubercle  is  in  quite  an  early  stage.  The  urine 
should  also  be  tested  for  albumen,  and  the  absence  of  stricture  or 
cancer  of  the  rectum  determined.  Operation. — A  director  should 
be  passed  through  the  fistula  into  the  bowel,  and  its  point  hooked 
down  and  brought  out  at  the  anus  by  the  index  finger,  which  has 
been  passed  up  the  rectum.  The  bridge  of  tissue,  which  some- 
times includes  the  external  sphincter,  is  then  divided  by  running 
a  curved  bistoury  along  the  director.  The  upward  prolongation 
of  the  fistula  beyond  the  internal  opening  (Fig.  318)  should  next 
be  laid  completely  open  into  the  cavity  of  the  bowel.  A  careful 
search  should  now  be  made  with  a  probe  for  all  secondary  fistulse 
or  lateral  sinuses,  and  these  laid  freely  open.  The  lining  mem- 
brane of  the  fistula  should  next  be  destroyed  by  scoring  it  with  a 
bistoury,  or  scraping  it  with  a  Volkmann's  spoon,  as  otherwise  the 
fistula  is  apt  to  reform.  The  wound  should  finally  be  filled  with 
iodoform  wool,  and  a  pad  and  T-bandage  applied.  When  there 
have  been  secondary  fistuLne  extending  widely  into  the  surround- 
ing tissue,  I  have  succeeded  in  greatly  lessening  the  time  of  heal- 
ing by  cutting  completely  away  the  lining  membrane  of  the  out- 
lying portions  and  bringing  the  raw  surfaces  together  by  suture. 

After  the  operation  the  bowels  should  be  kept  confined  for 
about  four  or  five  days  with  small  doses  of  opium,  and  then  re- 
lieved by  castor  oil  or  an  enema.  The  wound  should  be  dressed 
daily  with  iodoform  wool  lightly  i)ressed  into  it  to  insure  its  heal- 
ing from  the  bottom.  When  the  internal  opening  is  very  high  up 
a  stout  ligature  may  be  passed  and  made  to  cut  its  way  out,  the 
fistula  healing  behind  it.  Hut  as  this  takes  a  long  time,  it  is  bet- 
ter to  reduce  the  fistula  in  this  way  to  reasonable  limits  and  then 
divide  it.     'J"he  blind  external  -Awd  the  blind  internal  •a\-\o\x\(}i  as  a 


THE    SIMPLE    OR    FIBROUS    STRICTURE,  663 

rule  be  converted  into  complete  fistulje  by  forcing,  in  the  former 
case  a  director  up  the  fistula  into  the  bowel,  and  in  the  latter  by 
cutting  through  the  skin  on  the  point  of  a  bent  probe  hooked  into 
the  internal  opening,  and  made  to  project  under  the  skin.  Both 
are  then  treated  as  a  complete  fistula.  In  some  cases  of  blind 
external  fistulae  a  free  T-shaped  incision  will  suffice  without  cut- 
ting through  the  sphincter  or  entering  the  rectum. 

Polypi  generally  occur  as  pedunculated  growths  springing  from 
the  submucous  tissue,  usually  of  the  lower  part  of  the  rectum. 
They  vary  in  size  from  a  pea  to  a  cherry,  and  in  color  from  white 
or  pale  pink  to  a  deep  red.  The  two  chief  forms  are  ( i )  the  soft 
or  vascular,  which  show  microscopically  an  adenomatous  structure 
with  at  times  some  amount  of  myxomatous  degeneration,  and 
are  most  common  in  children  ;  and  ( 2 )  the  hard  or  fibrous,  which 
are  more  rare  and  generally  occur  in  adults. 

Sytnptoms. — Polypi  are  the  commonest  cause  of  bleeding  from 
the  rectum  in  children,  the  blood  escaping  not  only  during  but 
also  after  deftecation.  When  low  down  they  cause  straining,  per- 
haps a  mucous  discharge,  and  pain  after  defaecation  from  being 
caught  in  the  sphincter.  When  large  they  may  produce  prolapse 
or  intussusception.  Small  polypi  beyond  the  reach  of  the 
sphincter  may  cause  no  symptoms.  They  are  usually  detected 
by  sweeping  the  finger  well  round  the  rectum,  the  examination 
being  best  made  after  the  bowels  have  been  emptied  and  the 
polypus  brought  down  by  an  enema. 

The  treatment  consists  in  ligature  of  the  pedicle,  followed  by 
excision  of  the  growth.     They  do  not  recur. 

Villous  tumors  of  the  rectum  are  rare,  and  are  most  frequently 
met  with  in  patients  over  forty  years  of  age.  They  have  a  papillo- 
matous structure,  and  spring  from  the  mucous  membrane.  Fre- 
quent haemorrhages  and  the  passage  of  a  glairy  mucous  discharge 
are  the  chief  signs.  Removal  is  the  treatment.  They  are  apt  to 
recur  and  then  to  become  malignant. 

Stricture  of  the  rectum  may  be  divided  into  the  simple  and 
the  malignant. 

I.  The  sbiple  or  fibrous  stricture  may  be  caused  by  the 
fibroid  contraction  of  inflammatory  products  in  the  mucous  and 
submucous  coats,  or  of  cicatrices  following  simple,  syphilitic  or 
dysenteric  ulceration ;  by  injury,  or  operation  on  the  bowel ;  or  it 
may  be  the  result  of  pelvic  inflammations  {peri-  or para-metritis) . 

Pathology. — The  stricture  is  generally  situated  from  one  to  two 
inches  from  the  anus,  but  may  occur  at  any  part.  It  may  involve 
only  a  narrow  ring-like  portion,  when  it  is  called  annular ;  or  it 
may  include  an  inch  or  more  of  the  gut,  when  it  is  sometimes 
spoken  of  as  tubular.     The  strictured  portion  of  the  bowel  con- 


664  DISEASES   OF   REGIONS. 

sists  in  great  part  of  fibrous  tissue.  The  syphilitic  variety  is  often 
combined  with  condylomata  or  ulceration  about  the  anus,  and  the 
mucous  membrane  between  the  anus  and  the  stricture  is  fre- 
quently ulcerated.  The  bowel  above  is  generally  distended  with 
f?eces,  the  muscular  coat  hypertrophied,  and  the  mucous  mem- 
brane ulcerated;  whilst,  in  the  neighborhood  of  the  stricture,  the 
coats  are  often  so  thin  that  the  least  force  causes  them  to  give 
way.  Fistulae  often  form  below  the  stricture,  and  haemorrhoids 
are  a  frequent  concomitant. 

Symptoms  and  diagnosis. — Pain  and  difficulty  in  passing  a  mo- 
tion, constipation,  and  later,  constipation  alternating  with  diar- 
rhcea.  The  motions,  when  the  stricture  is  near  the  anus,  become 
small,  ribbon-like,  and  streaked  with  discharge.  There  is  a  fre- 
quent desire  to  defascate,  but  little  passes  except  wind  and  dis- 
charge, and  the  bowel  feels  as  if  it  had  not  been  empt^'ed.  In 
tight  strictures  or  in  strictures  with  ulceration  fistute  may  some- 
times form  about  the  anus,  and  the  patient  gets  worn  out,  and 
after  many  years  perhaps  of  suffering  may  die  of  an  attack  of  per- 
itonitis or  obstruction.  The  stricture  is  readily  detected  on  pass- 
ing the  finger,  but  is  often  so  tight  that  only  the  tip  can  be  got 
into  it.  When  this  is  the  case,  on  no  acoount  should  the  finger 
be  passed  through  it,  as  the  slight  force  of  passing  the  finger  may 
rupture  the  attenuated  walls  and  peritonitis  and  death  may  follow. 

Treatment. — As  a  rule,  gradual  dilatation  by  means  of  bougies, 
of  which  the  soft  flexible  ones  of  Mr.  Ooodsall  are  perhaps  the 
best,  should  be  first  attempted,  and  will  generally  be  successful ; 
but  the  stricture  must  be  kept  dilated  by  the  subsequent  occa- 
sional passage  of  a  bougie.  In  exceptional  cases,  where  the 
stricture  is  very  resistant,  a  bougie  may  be  tied  in.  Where  the 
parts  are  much  riddled  by  fistulae,  a  division  of  the  stricture  may 
be  necessary.  This  may  be  done  by  what  is  called  internal  or 
external  linear  proctotomy.  In  the  former  operation  the  knife, 
guided  by  the  finger,  is  introduced  through  the  stricture,  which  is 
then  divided  in  a  posterior  direction  ;  in  the  latter,  the  stricture, 
together  with  the  external  s])incter  and  other  interv^ening  soft 
parts,  are  completely  divided  down  to  the  coccyx. 

2.  Mai^ionant  or  cancerous  stricture. — Fathotoi^y. — Cancer 
in  all  its  f(jrms  may  occur  in  the  rectum,  but  the  most  common  is 
a  variety  of  carcinoma  known  as  the  columnar  or  adenoid.  It 
occurs  either  as  a  fungating,  more  or  less  distinct  tumor  project- 
ing into  the  lumen  of  the  bowel,  or  as  a  laminar,  no<lular,  or  ring- 
like infiltration  of  its  coats.  In  either  case,  it  is  at  first  covered  by 
apjjarently  unaltered  mucous  membrane,  which,  however,  is  sooner 
or  later  destroyed  by  ulceration,  leaving  an  ulcer  with  an  uneven, 
proliferating,  or  excavated  surface,  everted  edges  and  an  indurated 


MALIGNANT   OR   CANCEROUS   STRICTURE.  665 

base.  As  the  disease  extends  it  involves  the  muscular  coat,  and 
subsequently  the  surrounding  structures  and  organs,  gluing  them, 
as  it  were,  to  the  rectum,  and  finalling  converting  the  whole  into  a 
cancerous  mass.  The  lymphatic  glands  in  the  pelvis,  and  later  the 
inguinal  glands  and  others  more  removed,  become  affected,  and 
the  carcinoma  may  finally  be  disseminated,  secondary  growths 
being  more  especially  met  with  in  the  liver.  The  sytJiptoms  are 
often  very  insidious.  At  first  there  may  be  merely  some  uneasi- 
ness, hardly  amounting  to  pain,  about  the  anus  ;  then  more  or  less 
pain  on  defecation  is  noticed  ;  the  faeces  may  be  streaked  with 
mucus  or  with  blood,  and  a  slimy  discharge  may  be  present. 
Later  the  motions  become  small,  flattened,  or  pipe-like  when  the 
stricture  is  near  the  anus,  or  scybalous  when  some  distance  above. 
The  patient  strains  at  stool,  and  feels  as  if  his  bowel  had  not  been 
emptied  ;  then  there  is  constipation  alternating  with  dianhoea, 
and  an  offensive  sanious  discharge.  Emaciation  and  cachexia 
now  come  on,  with  more  local  pain,  and  the  patient  dies  of  ex- 
haustion, peritonitis,  or  during  an  attack  of  acute  obstruction. 

The  diagnosis  can  only  be  arrived  at  by  a  local  examination. 
The  anus  generally  appears  healthy,  though  probably  patulous, 
and  a  healthy  strip  of  mucous  membrane  generally  exists  between 
the  anus  and  the  growth.  When  the  growth  can  be  felt,  its  in- 
durated base,  and  when  ulceration  has  occurred,  the  everted  edges 
of  the  ulcer,  and  the  sanious  and  foul  discharge,  render  the  diag- 
nosis generally  easy.  When  beyond  the  reach  of  the  finger  it  may 
at  times  be  brought  down  by  asking  the  patient  to  strain.  The 
fungating  form  may  be  mistaken  for  a  villous  growth  ;  the  annular, 
for  a  simple  fibrous  stricture.  A  villous  growth  may  be  distinguished 
by  its  velvety  and  supple  feel,  by  its  not  ulcerating  and  breaking 
down,  by  the  absence  of  induration,  by  the  discharge  being  thin 
and  mucoid,  the  blood  bright  and  small  in  quantity,  and  the  rec- 
tum not  fixed,  and  by  the  duration  of  the  disease.  A  fibrous 
stricttire  may  be  knov/n  by  its  longer  duration,  by  being  less  in- 
durated than  the  cancerous  form,  by  the  bowel  not  being  fixed, 
and  when  due  to  syphilis,  by  the  absence  of  a  healthy  strip  of 
mucous  meinbrane  between  the  growth  and  the  anus. 

Treatment.— \{  the  disease  is  seen  sufficiently  early  and  before 
it  has  involved  the  surrounding  parts,  if  it  is  not  situated  too  high 
up  the  rectum,  and  if  the  general  condition  of  the  patient  is  other- 
wise favorable,  excision  of  the  growth  with  the  lower  end  of  the 
rectum  should  be  undertaken,  as  in  this  way  the  whole  may  be 
removed,  and  not  without  reasonable  hope,  in  some  of  the  less 
malignant  forms  of  the  disease,  of  its  not  returning.  Some  cases 
have  been  reported  where  it  has  not  done  so  for  upwards  of  four 
years.  Previous  to  removal  of  the  rectum,  I  now  invariably  per- 
28* 


666  DISEASES   OF   REGIONS. 

form  inguinal  colotomy,  since  after  this  operation  there  is  less  risk 
of  the  wound  left  by  the  excision  becoming  septic.  Where  re- 
moval seems  impracticable,  or  otherwise  unadvisable,  such  pallia- 
tive measures  should  be  adopted  as  may  render  the  last  few 
months  or  years  of  the  patient's  life  as  comfortable  as  possible. 
Thus  the  bowels  should  be  kept  gently  relaxed,  the  diet  regulated, 
and  the  pain  relieved  by  morphia  suppositories.  In  this  way  the 
patient  can  often  follow  his  occupation  in  comparative  comfort 
and  with  little  inconvenience.  Should,  however,  there  be  very 
frequent  calls  to  defecate,  much  pain  and  irritation  on  the  pas- 
sage of  f?eces,  or  obstruction  threaten  or  have  already  occurred, 
colotomy  should  be  performed  (p.  612).  This  operation  should 
not,  as  is  too  frequently  the  case,  be  regarded  merely  as  a  last 
resource,  to  be  undertaken  when  obstruction  has  come  on,  as  then 
the  danger  of  the  operation  is  greatly  increased.  Nor  should  it 
be  undertaken  in  every  instance,  since  the  inconvenience  caused 
by  the  cancer  is  not  always  sufficient  to  justify  the  patient  under- 
going the  risk. 

Excision  of  the  rectum  may  be  performed  if  the  finger  can  be 
passed  beyond  the  growth  ;  if  the  growth  is  movable  ;  if  the  glands 
are  not  involved,  and  if  the  patient  is  otherwise  fairly  healthy. 
The  patient  having  been  placed  in  the  lithotomy  position  and  a 
staff  introduced  into  the  bladder,  a  curved  bistoury  should  be 
passed  along  the  finger  up  the  rectum,  and  its  point  made  to 
emerge  near  the  coccyx,  and  the  intervening  tissues  cut  through 
in  the  middle  line.  By  this  incision  a  free  exposure  is  obtained. 
Lateral  incisions  are  next  made  on  each  side  of  the  anus,  meeting 
in  front,  and  the  bowel  is  rapidly  cleared  either  with  the  finger 
or  with  the  handle  of  the  scalpel  from  the  tissues  of  the  ischio- 
rectal fossa.  The  lower  part  of  the  rectum  is  now  dissected  more 
carefully  from  the  urethra  and  prostate,  and  when  it  has  been 
sufficiently  freed,  the  ecraseur  is  placed  above  the  growth,  and 
the  rectum  removed,  care  being  taken  that  the  cord  when  tight- 
ened is  not  pulled  down  below  the  sj^ot  where  it  is  intended  to 
sever  the  bowel.  If  preferred  the  scissors  may  be  substituted  for 
the  ecraseur,  the  vessels  being  then  tied  as  they  are" cut.  When 
the  growth  does  not  involve  the  whole  of  the  bowel,  a  strip  of 
mucous  membrane  should,  if  possible,  be  left.  The  wound  should 
be  plugged  for  twenty-four  hours  with  iodoform  gauze  if  there  is 
much  oozing,  and  the  parts  subsequently  irrigated  frequently. 
More  of  the  rectum  may  be  rcmove(l  by  resection  of  the  coccyx 
and  lower  part  of  the  sacrum,  the  incision  extending  backwards 
and  to  the  left  side  {Kraske's  operation). 


DISEASES    OF    THE    URINARY    ORGANS.  667 

DISEASES  OF  THE  URINARY  ORGANS. 
SURGICAL   DISEASES    OF   THE    KIDNEYS. 

Nephritis,  or  inflammation  of  the  kidney,  as  met  with  in  sur- 
gical practice,  is  commonly  the  result  of  long-standing  disease  of 
the  bladder,  urethra,  or  prostate,  or  of  the  impaction  of  a  calculus 
in  the  ureter  or  pelvis  of  the  kidney.  Traumatic  nephritis  has 
already  been  alluded  to  under  Injuries  of  the  Abdomen. 

The  inflammation,  when  secondary  to  other  diseases  of  the 
urinary  organs,  may  be  produced  in  several  ways.  Thus,  it  may 
be  due  to — i.  Tension  in  the  tubules  of  the  kidney,  resulting  from 
obstruction  to  the  overflow  of  urine  consequent  upon  long-stand- 
ing stricture  of  the  urethra  or  prostatic  enlargement.  Under  these 
circumstances  the  inflammation  falls  chiefly  on  the  cortical  and 
medullary  substance  of  the  kidney  {^interstitial  nephritis').  2.  The 
presence  of  septic  matter  in  the  pelvis  of  the  kidney  due  to  (a) 
the  spread  of  inflammation  up  the  ureter  from  the  bladder,  or  \b) 
decomposition  of  pent-up  urine  behind  an  impacted  calculus  in 
the  ureter  or  pelvis  of  the  kidney.  In  this  case  the  inflammation 
is  of  a  septic  or  suppurative  character,  and  although  it  may  chiefly 
affect  either  the  lining  membrane  of  the  pelvis  ^pyelitis)  or  the 
substance  of  the  organ  {suppurative  nephritis),  it  more  generally 
involves  both  {pyelo- nephritis).  At  times,  the  pelvis  and  calices 
become  distended  with  the  pus,  and  the  kidney  is  finally  con- 
verted into  a  suppurative  cyst  {pyo-nephrosis).  3.  Reflex  irri- 
tation of  the  kidney  through  the  nervous  system,  as  from  the 
passage  of  a  catheter  in  stricture  or  enlarged  prostate,  or  the  per- 
formance of  some  operation  on  the  urinary  organs,  as  lithotomy 
or  lithotrity.  Here  the  inflammation  is  usually  transitory,  unless 
the  kidneys  are  already  suff"ering  from  the  effects  of  urinary  ob- 
struction, when  it  may  run  on  to  suppuration. 

Simple  interstitial  nephritis  usually  begins  in  an  insidious  man- 
ner, the  symptoms  of  the  kidney  mischief  being  obscured  by  the 
primary  affection  of  the  urinary  organs  from  which  the  patient  is 
probably  suffering.  It  may  be  suspected,  however,  where  there 
is  continual  loss  of  strength,  increasing  pallor  and  gradual  wast- 
ing. The  urine  is  passed  in  large  quantities,  and  is  of  low  specific 
gravity.  Albumen  at  first  is  absent,  or  only  present  in  small 
quantities,  and  although  later  it  may  be  increased  in  amount,  it 
is  often  difficult  to  estimate  in  consequence  of  the  pus,  mucus, 
or  blood  which  may  be  present,  owing  to  the  diseased  bladder  or 
other  urinary  trouble.  Should  these  troubles  not  be  relieved,  the 
symptoms  of  the  kidney  affection  become  more  marked  ;  there  is 
loss  of  appetite,  a  furred  tongue,  nausea,  perhaps  vomiting,  in- 
crease of  temperature  at  nights,  a  hot  skin,  thirst,  and  emaciation. 


668  DISEASES   OF   REGIONS. 

This  condition  may  last  for  months,  when  the  symptoms  may 
gradually  subside  if  the  primary  trouble  can  be  removed  ;  or  it 
may  terminate  in  exhaustion  and  death ;  or  in  an  acute  attack  of 
suppurative  nephritis. 

The  ireatincjit  consists  essentially  in  removing  the  cause,  where 
this  is  practicable,  and  carefully  avoiding  all  sources  of  irritation 
that  may  re-act  through  the  nervous  system  on  the  kidney.  Thus, 
all  instrumentation  must  be  done  in  the  gentlest  possible  manner, 
and  decomposition  of  the  urine  prevented  by  washing  out  the 
bladder  with  antiseptic  solutions.  The  patient  at  the  same  time 
should  be  kept  in  bed,  and  restricted  to  a  non-stimulating  and 
chiefly  fluid  diet ;  whilst  hot  flannels  and  occasionally  dry  cups 
should  be  applied  to  the  loins. 

Suppurative  or  septic  nephritis. — Under  this  head  is  included 
suppuration  of  the  pelvis  and  of  the  substance  of  the  kidney, 
since  both,  as  a  rule,  are  simultaneously  affected,  and  the  symptoms 
are  similar  or  identical.  Pyonephrosis  is  considered  separately. 
Suppurative  nephritis  generally  occurs  suddenly  in  the  course  of 
long-standing  disease  of  the  lower  urinary  organs,  attended  with 
septic  decomposition  of  the  urine  in  the  bladder.  It  is  probably 
almost  always  due  to  the  septic  micro-organisms  reaching  the 
kidneys  from  the  bladder  by  the  ureters.  It  is  usually  preceded 
by  simple  interstitial  nephritis. 

The  symptoms,  which  frequently  first  come  on  after  some  ope- 
rative procedure  on  the  urethra  or  bladder,  are  usually  ushered  in 
by  a  rigor  followed  by  sweating  and  fever.  The  tongue  becomes 
dry  and  red  ;  the  lips  and  teeth  are  covered  with  sordes ;  the 
appetite  is  lost ;  nausea,  vomidng,  or  diarrhoea  sets  in,  and  the 
patient  usually  sinks  into  a  typhoid  state  and  dies.  There  is  no 
oedema,  and  the  urine  usually  continues  abundant  and  loaded 
with  pus  to  the  end,  though  it  may  at  times  be  diminished  in 
quantity  or  even  suppressed.     It  may  or  may  not  contain  blood. 

l^eatment  as  a  rule  is  of  little  avail ;  but  the  same  general  plan 
should  be  followed  as  described  under  simple  interstitial  nephritis. 
Where  the  cause  can  be  effectually  removed,  recovery  may  at 
times  take  place. 

Circumscribed  abscess  may  occur  in  the  kidney  substance  or 
in  the  cellular  tissue  around  {peri-neplirilic  abscess).  It  must  be 
distinguished  from  pyonephrosis,  in  which  the  pelvis  and  calices 
are  distended  with  pus.  Cause. — It  is  generally  due  to  injury, 
pysemia,  or  renal  calculus.  When  it  occurs  in  the  peri-renal 
tissue,  it  may  be  consecutive  to  abscess  or  other  disease  of  the 
kidney  itself;  or  it  may  be  due  to  causes  independent  of  the 
kidney,  as  cold,  disease  of  the  spine,  and  other  conditions  lead- 
ing to  the  formation  of  abscesses.     'J'he  symptoms  are  those  of 


PYONEPHROSIS.  669 

deep  suppuration,  attended  with  certain  peculiarities  on  account 
of  its  situation,  which,  however,  cannot  be  here  discussed.  The 
treatment  consists  in  making  a  free  incision  into  the  abscess 
through  the  loin. 

Hydronephrosis  is  an  over-distension  of  the  pelvis  of  the 
kidney  with  altered  urine.  Cause. — Any  condition  in  the  bladder, 
ureter,  or  pelvis  of  the  kidney,  producing  mechanical  obstruction 
to  the  outflow  of  urine.  These  conditions  may  be  divided  into 
the  congeiiital,  such  as  twists  of  the  ureter,  smallness  of  its  vesical 
orifice,  etc.,  and  into  the  acquired,  such  as  impaction  of  a  calculus 
in  the  ureter,  enlarged  prostate,  stricture  of  the  urethra,  etc. 
Pathology. — The  pelvis,  and  subsequently  the  calices  of  the  kidney, 
become  distended  with  urine,  the  cortical  substance  is  destroyed 
by  the  pressure  of  the  retained  urine,  and  the  whole  organ  finally 
converted  into  an  irregular  cyst.  The  hydronephritic  fluid  con- 
sists of  altered  urine,  and  may  contain  hardly  a  trace  of  urea. 
Symptoms. — When  the  obstruction  is  complete,  a  tumor  is  found 
in  the  abdomen,  and  often  attains  a  great  size.  It  may  then  be 
mistaken  for  an  ovarian  cyst,  an  hydatid  cyst  of  the  liver  or 
omentum,  a  distended  gall-bladder,  a  splenic  tumor,  a  sohd  tumor 
of  the  kidney,  or  pyonephrosis.  From  these  a  hydronephrotic 
kidney  may  generally  be  distinguished  by  the  colon  being  in  front 
of  it,  by  the  presence  of  fluctuation,  by  its  dulness  to  percussion, 
by  its  situation  in  the  flank,  by  its  projection  more  or  less  in  the 
loins,  by  the  uterus  being  free  and  not  displaced,  and  by  the  ab- 
sence of  febrile  symptoms.  Z;ra/w<?///'.— Aspiration,  unless  the 
tumor  is  small  and  painless,  when  it  may  be  left  alone,  should 
first  be  tried  ;  but  if  the  fluid  rapidly  re-accumulates,  nephrotomy 
will  usually  be  required. 

Pyonephrosis  is  the  distension  of  the  pelvis  and  cahces  of  the 
kidney  with  pus,  and  the  subsequent  destruction,  more  or  less 
complete^  of  the  medullary  and  cortical  substance,  the  whole  kidney 
being  at  length  converted  into  a  large  multilocular  cyst.  This 
cyst  may  rupture  into  the  peritoneal  cavity  or  colon,  or  into  the 
surrounding  tissue,  causing  a  perinephritic  abscess.  Causes. — It 
may  follow  pyelitis,  owing  to  the  blocking  of  the  ureter  with  a 
clot  of  blood  or  pus ;  or  it  may  be  engrafted  on  hydronephrosis, 
consequent  upon  tapping  or  injury.  At  times  it  may  be  the  result 
of  tubercle,  or  of  a  direct  injury  of  the  kidney.  Symptoms. — In 
addition  to  a  tumor  in  the  abdomen  with  charcters  similar  to 
those  of  hydronephrosis,  there  will  be  pain  in  the  tumor,  especially 
on  pressure,  febrile  disturbance,  and  if  the  obstruction  of  the 
ureter  is  incomplete,  pus  in  the  urine  from  time  to  time.  Treat- 
ment.— Having  aspirated  the  tumor,  and  discovered  the  presence 
of  pus,  nephrotomy  is  generally  indicated,  especially  if  the  tumor 


670 


DISEASES   OF   REGIONS. 


rapidly  refills,  and  if  there  is  much  pain  or  febrile  disturbance,  or 
rupture  of  the  cyst  appears  imminent.  If,  after  nephrotomy,  how- 
ever, the  cyst  does  not  shrink  and  cease  to  suppurate,  nephrec- 
tomy must  be  done,  as  otherwise  lardaceous  disease  or  hectic 
may  carry  off  the  patient,  or  blood-poisoning  may  ensue  from  the 
discharge  becoming  septic,  or,  as  sometimes  happens  when  the  ob- 
struction of  the  ureter  is  relieved  to  some  extent  by  the  nephro- 
tomy, the  decomposing  pus  may  make  its  way  into  the  bladder, 
set  up  cystitis,  and  the  other  kidney  become  affected.  Under 
some  circumstances,  as  where  the  kidney  is  reduced  to  little  more 
than  a  shell,  it  will  be  better  at  once  to  perform  nephrectomy. 

Renal  calculi  generally  consist  of  uric  acid  or  of  oxalate  of 
lime,  and  are  formed  by  the  deposit  of  the  urinary  salts,  either  in 
the  tubules  or  calices  of  the  kidney.  Whilst  still  small,  they  may 
pass  down  the  ureter  into  the  bladder,  and  subsequently  form  the 
nucleus  of  a  vesical  calculus,  or  be  voided  with  the  urine.  Or 
they  may  remain  in  the  kidney,  either  in  its  substance,  or  in  the 
pelvis  or  one  of  the  calices,  and  there  increase  in  size  by  the  suc- 
cessive deposit  upon  them  of  the  urinary  salts.     They  may  be 

single  or  multiple,  and  vary  in  size 
and  shape  from  a  small  rounded  body 
the  size  of  a  mustard-seed  to  a  large 
branched  mass  filling  the  pelvis  and 
caHces  (Fig.  321).  Their  presence 
may  set  up  inflammation  of  the 
pelvis  of  the  kidney  {calculous  pye- 
litis), or  of  its  substance  {simple  or 
suppurative  nephritis).  Or  they  may 
block  the  ureter,  in  which  case  the 
kidney  may  become  distended  with 
altered  urine  {hydronephrosis),  or 
with  pus  {pyonephrosis)  ;  whilst  at 
times,  they  may  exist  for  years,  caus- 
ing little  or  no  damage.  Not  infre- 
quently there  may  be  a  stone  in  both 
kidneys. 

Symptoms. — At  times  there  may 
be  no  symptoms,  even  although  the 
stone  is  of  large  size.  Generally, 
however,  there  will  be  pain,  retrac- 
tion of  the  testicle,  increased  fre- 
quency of  micturition,  and  the  presence  of  blood,  pus  or  crystals 
in  the  urine.  The  pain,  which  is  worse  after  exercise,  is  usually 
situated  in  the  loin  of  the  affected  side,  and  is  often  felt  shooting 
down  the  course  of  the  ureter  to  the  groin  and  front  of  the  thigh. 


Renal  calculus  blocking  up  pelvis  of 
kidney  and  commencement  of 
ureter.  (St.  Bartholomew's  Hos- 
pital Museum.) 


THE  TUBERCULOUS   KIDNEY.  67 1 

Blood  is  generally  present  in  the  urine  from  time  to  time,  espec- 
ially after  violent  exercise,  and  pus  and  mucus  in  varying  quanti- 
ties, if  pyelitis  has  been  set  up,  may  also,  as  a  rule,  be  detected. 
The  urine,  notwithstanding  the  presence  of  the  pus,  is  generally 
acid,  and  the  bladder,  prostate,  and  urethra  are  found  free  from 
disease.  Should  hydronephrosis  or  pyonephrosis  have  been  pro- 
duced, a  tumor  will  then  be  discovered  in  the  abdomen,  and 
there  may  no  longer  be  any  pus  or  blood  in  the  urine.  In  the 
latter  instance  there  may  be  in  addition  constitutional  signs  of 
suppuration  (see  hydro-  and  pyonephrosis') .  Should  the  stone 
escape  from  the  pelvis  and  enter  the  ureter,  its  passage  down  that 
tube  will  be  attended  with  intense  pain  {renal  colic).  The  pain 
occurs  suddenly  and  darts  towards  the  groin,  testicle  and  thigh, 
and  is  accompanied  by  nausea  or  vomiting,  syncope,  profuse  per- 
spiration, and  blood  and  urates  in  the  urine.  After  lasting  a  few 
hours  to  several  days  the  symptoms  suddenly  cease,  owing  to  the 
calculus  dropping  from  the  lower  end  of  the  ureter  into  the 
bladder,  or  if  too  large  to  pass  beyond  the  infundibulum,  becom- 
ing displaced  into  the  pelvis  of  the  kidney.  Hence  successive 
attacks  of  renal  colic  may  be  due  either  to  the  same  stone  block- 
ing up  from  time  to  time  the  entrance  of  the  ureter,  or  to  the 
passage  of  different  stones. 

Treatment. — For  an  account  of  the  preventive  treatment  a 
work  on  medicine  must  be  consulted.  When  a  stone  has  formed 
and  medical  treatment  has  failed  to  give  relief  after  long- 
continued  trial,  and  the  patient's  hfe  is  rendered  unbearable  from 
constant  pain  or  compulsory  recumbency,  an  operation  must  be 
undertaken  for  his  relief.  This  may  consist  in  nephrolithotomy, 
nephrotomy,  or  nephrectomy.  Where  the  kidney  is  but  little  if 
at  all  damaged,  the  first  is  clearly  indicated ;  but  if,  on  exploring 
the  kidney,  the  stone  cannot  be  felt  even  on  puncture  with  a 
needle,  or  on  incision  and  exploration  with  the  finger,  it  becomes 
a  question  whether  nephrectomy  should  be  done,  or  the  kidney 
left  ///  situ  and  the  wound  merely  closed.  If  hydronephrosis  or 
pyonephrosis  has  supervened,  nephrotomy  is  required,  or  possibly 
nephrectomy.  For  renal  colic  hot  baths,  hot  fomentations,  and 
opium,  or  injections  of  morphia,  must  be  given  to  assuage  the 
pain. 

The  TUBERCULOUS  KIDNEY  need  only  briefly  be  referred  to  here, 
as  it  is  more  fully  described  in  works  on  Medicine.  This  affec- 
tion may  occur  in  the  course  of  general  tuberculosis,  or  involve 
the  kidney  secondarily  to  the  bladder  or  prostate  ;  or  it  may  be- 
gin primarily  in  the  kidney  and  thence  spread  downwards.  The 
symptoms  to  which  it  gives  rise  are  very  similar  to  those  of  renal 
calculus,  and   it  may  be  impossible  to  distinguish  them.     Thus, 


672  DISEASES   OF   REGIONS. 

there  is  increased  frequency  of  micturition  ;  pus,  and  at  times 
blood,  in  the  urine,  and  often  pain  in  the  loin  ;  whilst  later  there 
will  be  a  tumor  in  the  abdomen  with  characters  like  those  de- 
scribed under  pyonephrosis.  The  presence  of  tubercle  elsewhere, 
and  of  hectic  or  emaciation,  and  the  discovery  of  the  tubercle 
bacillus  in  the  urine,  will  point  to  the  nature  of  the  case.  Treat- 
ment.— The  constitutional  remedies  for  tubercle  should  be  em- 
ployed, and  when  pyonephrosis  or  a  perinephritic  abscess  has 
formed,  nephrotomy  may  be  resorted  to  ;  but  nephrectomy  should 
never  be  undertaken  unless  it  seems  clear  that  the  disease  is  lim- 
ited to  one  kidney,  the  exception  rather  than  the  rule. 

Cysts  of  the  kidney. — Serous  and  hydatid  cysts  may  occur  in 
the  kidney  as  elsewhere,  but  the  question  of  their  diagnosis,  which 
is  often  attended  with  much  difficulty,  cannot  be  discussed  here. 
They  are  very  rare.  Cysts  of  small  size  are  common  in  connec- 
tion with  some  forms  of  chronic  Bright's  disease  ;  but  these  only 
concern  the  pathologist.  The  so-called  cystic  degeneration,  due 
to  urinary  obstruction,  pyelitis,  pyonephrosis,  etc.,  has  already 
been  alluded  to. 

Tumors  of  the  kidney. — Sarcoma  and  carcinoma  are  the  only 
tumors  which  need  be  referred  to.  They  are  characterized  by  a 
swelling  in  the  region  of  the  kidney,  dulness  in  the  flank,  the 
presence  of  the  colon  in  front  of  them,  the  absence  of  fluctuation 
unless  they  are  of  a  cystic  character,  blood  in  the  urine,  and 
rapid  emaciation.  Treat?nent. — If  the  tumor  is  diagnosed  whilst 
still  small,  nephrectomy  may  be  done,  though  an  early  recurrence 
is  only  too  probable.  When  the  tumor  is  of  large  size  and  has 
formed  adhesions  to  the  neighboring  parts,  it  is  beyond  the  reach 
of  legitimate  surgery. 

SuppRKSsi()N  OF  URINE  is  the  term  applied  to  the  non-secretion 
of  urine  by  the  kidneys,  and  must  not  be  confounded  with  reteji- 
tion  of  urine,  in  which  the  urine  is  secreted  as  usual,  but  its  pass- 
age from  the  bladder  is  obstructed.  In  the  former  the  bladder 
is  empty ;  in  the  latter  distended.  Suppression  as  met  with  in 
surgical  practice  is  generally  due  to  the  shock  following  an  opera- 
tion or  injury  on  the  urinary  organs  in  a  patient  suffering  from 
chronic  renal  disease.  If  not  relieved,  coma,  convulsions,  and 
death  from  uraemia  quickly  ensue.  Ircatmcnt. — Dry  or  wet  cup- 
ping the  loins,  hot  vapor  baths,  free  purging  as  by  elaterium  or 
croton  oil,  injections  of  ])ilocarpine,  and  hot  enemata  per  rectum, 
are  at  times  successful  in  relieving  the  congested  kidney. 

Operations  on  the  Kidney. 
Aspiration  of  the  kidney  may  be  performed  either  for  the  pur- 


NEPHRECTOMY.  673 

pose  of  diagnosing  a  renal  swelling,  or  for  the  relief  of  such  affec- 
tions as  hydronephrosis,  pyonephrosis,  or  hydatid  or  blood  cysts. 
It  should  be  done  with  the  ordinary  precautions,  any  prominent 
or  fluctuating  spot  being  chosen  for  the  puncture. 

Nephrotomy  consists  in  making  an  incision  into  the  kidney  for 
the  purpose  of  evacuating  and  draining  the  fluid  or  pus  in  the 
case  of  hydronephrosis,  pyonephrosis,  hydatid  cyst,  abscess,  etc. 
The  tumor  may  be  exposed  by  the  lumbar  or  lateral  incision  as 
described  in  nephrectomy.  An  incision  is  made  into  the  kidney, 
the  fluid  allowed  to  run  out,  the  wound  thoroughly  irrigated  with 
some  antiseptic  solution  and  insufflated  with  iodoform,  a  large- 
sized  drainage-tube  inserted  into  it,  and  voluminous  dressings  of 
absorbent  cotton  and  the  hke  applied  to  receive  the  subsequent 
discharges. 

Nephro-lithotomy  consists  in  cutting  into  a  kidney  for  the 
purpose  of  extracting  a  calculus.  The  kidney  may  be  exposed 
either  by  the  lumbar  or  lateral  incision  as  described  in  nephrec- 
tomy. If  a  stone  is  felt,  an  incision  should  be  carefully  made 
over  it,  the  finger  or  forceps  introduced,  and  the  stone  extracted. 
If  one  cannot  be  felt,  a  needle  should  be  thrust  into  the  kidney 
at  several  situations,  and  this  failing,  an  incision  should  be  made 
into  it,  and  the  finger  and  a  probe  introduced  to  search  for  stone. 
A  drainage-tube  should  be  placed  in  the  wound,  and  an  antiseptic 
and  absorbent  dressing  applied.  The  urine  will  at  first  escape 
through  the  wound,  but  will  cease  to  do  so,  as  a  rule,  after  a 
longer  or  shorter  interval. 

Nephrectomy,  or  removal  of  the  kidney,  may  be  done  for — 
I.  A  large  renal  calculus.  2.  Tuberculous  disease  with  exhaust- 
ing discharge.  3.  Hydronephrosis.  4.  Malignant  and  other 
tumors.  5.  Movable  kidney  attended  with  severe  neuralgic 
pain.  The  operation  may  be  done  without  opening  the  periton- 
eum either  by  a  lumbar  or  a  lateral  incision,  or  through  the  peri- 
toneal cavity,  the  incision  being  then  made  either  in  the  linea 
alba  or  linea  semilunaris. 

The  extra-peritoneal  operation. — If  the  incision  is  made  in  the 
lumbar  region  it  may  be  vertical,  T-shaped,  or  obhque  like  that 
of  colotomy.  If  the  lateral  incision  is  chosen  it  should  be  made 
obliquely  from  near  the  tip  of  the  last  rib,  towards  the  anterior 
superior  spine  of  the  ilium.  It  is  the  one  I  have  always  employed 
myself,  and  one  now  in  common  use  at  St.  Bartholomew's,  its 
advantages  being  that  it  combines  the  facilities  of  the  intraperi- 
toneal and  the  greater  safety  of  the  lumbar  incision,  as  it  does 
not  involve  opening  the  peritoneal  cavity.  The  kidney  having 
been  exposed  by  any  of  these  incisions,  the  capsule  should  be 
opened,  the  finger  introduced,  and  the  kidney  enucleated  from  its 
29 


674  DISEASES   OF    REGIONS. 

capsule ;  the  renal  artery  and  vein  should  then  be  securely  tied 
with  a  silk  ligature  passed  round  them  by  an  aneurysm-needle, 
and  the  ureter  separately  in  a  similar  way.  The  kidney  may  now 
be  removed  by  cutting  through  the  pedicle  with  scissors,  and  the 
wound  drained  and  dressed  antiseptically. 

The  intra-peritoneal  operation. — This  consists  in  opening  the 
peritoneal  cavity  by  one  of  the  incisions  mentioned  above,  draw- 
ing the  intestines  aside,  and  then  exposing  the  kidney  by  cutting 
through  the  peritoneum  in  front  of  it  external  to  the  colon.  The 
vessels  are  then  tied  separately,  the  kidney  removed  and  the  peri- 
toneum united,  the  same  precautions  being  adopted  as  after  an 
ovariotomy.  A  drain-tube  is  passed  by  some  surgeons  through  a 
counter-opening  in  the  loin,  and  the  end  of  the  ureter  brought 
out  of  the  wound. 

The  dangers  of  nephrectomy  are — i.  Severe  shock.  2.  Exces- 
sive haemorrhage.  3.  Suppression  of  urine  from  disease  or  ab- 
sence of  the  opposite  kidney.  4.  Peritonitis  from  wounding  the 
peritoneum.  5.  Laceration  of  the  colon.  6.  Inclusion  of  the 
vena  cava  in  the  ligature  of  the  pedicle  and  injury  of  the  duo- 
denum in  operating  on  the  right  side. 

Nephrorrhaphy  is  an  operation  for  fixing  a  floating  or  movable 
kidney  by  exposing  the  kidney  in  the  loin,  and  attaching  it  with 
sutures  to  the  parietes.  It  should  only  be  done  where  there  is  in- 
tense pain  and  constant  suffering  which  palliatives  have  failed  to 
relieve. 

Urinary  Deposits  and  Calculi. 

Urinary  deposits  are  divided  into  the  unorganized  and  the 
organized.  A.  The  unorganized  consists  of  the  urates,  the  uric 
acid,  the  oxalate  of  hme,  the  phosphates,  the  cystic  oxide,  the 
uric  oxide  and  the  carbonate  of  lime.  Only  the  more  common 
of  these  are  described. 

1.  The  urates,  formerly  called  lithates,  are  the  most  common  of 
the  urinary  deposits,  and  are  formed  by  the  combination  of  uric 
acid  with  ammonia,  soda,  or  lime.  They  occur  in  acid  urine  as  an 
amorphous  sediment,  varying  in  color  from  a  white  or  a  pale  fawn 
to  a  brick-dust  red.  They  only  appear  as  the  urine  cools,  and 
disappear  again  on  the  application  of  heat,  or  on  adding  alkalies. 
Though  generally  amorphous,  they  sometimes  i)resent  the  crystal- 
line forms  seen  in  P'ig.  322.  The  urate  of  ammonia  occurs  in 
alkaline  urine. 

2.  The  uric  acid  deposits,  which  are  the  next  most  common, 
occur  only  in  very  acid  urine,  as  a  yellowish-pink,  red,  or  brick- 
dust  red  crystalline  sediment.  The  crystals  are  often  of  large 
size,  and  the  deposit  is  then  known  as  7rd  sand  ox  gravel.     They 


URINARY   DEPOSITS. 


675 


usually  occur  as  rhombic  prisms,  or  long  oval  plates  with  acute 
angles,  and  are  often  mixed,  forming  rosettes.  The  various  kinds 
are  seen  in  Fig.  323.     They  are  soluble  in  alkalies.     The  causes 


Fig.  322. 


Fig.  323. 


Urates.     (Bryant's  Surger>'.) 


Uric  acid  crystals.     (Bryant's  Surgery.) 


of  the  presence  of  uric  acid,  as  well  as  of  the  urates,  are  :   i. 
Rapid  tissue  waste,  as  in  fevers;   2.  Over-indulgence  in  animal 


Fig.  324. 


Fig.  325. 


Crystals  of  oxalate  of  lime.     (Bryant's  Surgery.)        Phosphate  of  lime.     (Br>'ant's  Surgery.) 

food;  3.  Dyspepsia  ;  4.  Congestion  of  the  kidney  ;  5.  Gout ;  and 
6.  Deficient  action  of  the  skin. 


676 


DISEASES   OF   REGIONS. 


3.  The  oxalate  of  lime  is  a  crystalline  deposit  and  assumes  two 
forms,  the  octahedral  and  the  dumb-bell  crystals  (Fig.  324).  On 
holding  the  urine  up  to  the  light  the  crystals  as  minute  shining 
particles  are  seen  in  it.  The  causes  are  :  i.  Nervous  exhaustion 
from  overwork  or  sexual  excesses.  2.  Dyspepsia  induced  by  sac- 
charine food,  excess  of  alcohol,  or  vegetable  diet. 

4.  Phosphatic  deposits  occur  in  three  forms,  {a)  phosphate  of 
lime,  {b)  phosphate  of  ammonia  and  magnesia,  or  triple  phos- 
phates, {c)  the  two  former  mixed,  or  the  fusible  phosphates,  i^d) 
Phosphate  of  lime  forms  a  white  cloud  or  amorphous  deposit  of  pale 
granules  or  spheroids,  two  of  which  adhering  form  the  so-called 
false  dumb-bell;  or  a  crystalline  deposit  of  six-sided  prisms  col- 
lected into  sheaths  or  bundles  (Fig.  325).  It  may  be  mistaken 
for  albumen,  or  when  in  considerable  quantites  for  pus  or  mucus. 
The  urine  is  usually  alkaline,  but  may  be  neutral  or  even  feebly 

acid.       (^)    The   ammo- 
'^'<^-  326.  nio-maguesiiim phosphates 

occur  in  the  form  of  large 
triangular  prisms  with 
truncated  extremities  ;  as 
four-sided  prisms;  as  six- 
sided  plates  ;  and  as  foli- 
aceous  stellar  prisms  on 
adding  ammonia  (Fig. 
326).  The  urine  is  nat- 
ural in  color,  neutral  or 
alkaline,  with  a  foetid  am- 
moniacal  odor.  Causes. 
— Phosphatic  deposits  are 
due  to  local  disease  or  in- 
jury of  the  urinary  or- 
gans, such  as  may  be  in- 
duced by  spinal  mischief, 
a  foreign  body  in  the 
bladder,  etc.  The  mu- 
cus or  bacteria  in  the  bladder  decomposes  the  urea  into  carbonate 
of  ammonia,  which  converts  the  soluble  acid  phosphates  into 
insoluble  alkaline  phosphates. 

Carbonate  of  lime,  cystic  oxide,  and  itric  oxide,  are  too  rare  to 
require  description. 

B.  7he  organized  deposits. — To  these  belong  pus,  blood,  mucus, 
epithelium,  renal  casts,  spermatozoa,  and  fungi.  P//s  occurs  as  a 
thick  sediment,  and  may  be  recognized  by  the  urine  containing 
albumen,  and  by  the  microscopical  api)earance  of  the  pus-corpus- 
cles (p.  37).     It  may  be  due  to  cystitis,  pyelitis,  gonorrhoea,  leu- 


Phosphates  of  ammonia  and  magnesia  (triple  phos 
phalesj.     (Bryant's  Surgery.) 


THE    OXALATE    OF    LIME,  OR    MULBERRV    CALCULL  677 

corrhoea,  and  abscess  in  any  part  of  the  urinary  tract.  Urine 
containing  7uucus  becomes  gelatinous  and  ropy  on  adding  liquor 
potassse.  Blood  may  be  recognized  by  the  urine  being  smoky  or 
red,  by  the  ozonic  ether  test,  and  by  the  microscope  and  spectro- 
scope. See  Hcematuria  (p.  69S).  Epithelium,  renal  casts,  sper- 
matozoa, diudi  fungi  may  be  detected  by  the  microscope. 

Urinary  calculi  are  commonly  spoken  of  as  renal,  vesical  and 
prostatic,  according  as  they  occur  in  the  kidney,  bladder  or  pros- 
tate. Renal  calculi  are  formed  in  the  kidney,  and  hav^e  already 
been  described  (p.  670).  Prostatic  calculi  are  formed  in 
the  racemose  glands  of  the  prostate,  and  will  be  further  referred 
to  under  diseases  of  that  organ  (p.  702).  Vesical  calculi  may 
originate  in  the  bladder,  or,  as  is  more  commonly  the  case,  in  the 
kidney,  whence  they  pass  into  the  bladder,  and  there  increase  in 
size  by  the  excessive  deposit  upon  them  of  the  same  or  other  of 
the  urinary  salts.  The  calculi  most  frequently  met  with  in  this 
situation  are  (i)  the  uric  acid,  (2)  the  oxalate  of  lime,  and  (3) 
the  fusible  or  mixed  phosphates.  The  rarer  forms  are  (4)  the 
urate  of  ammonia  ;  (5)  the  cystic  oxide,  or  cystine  ;  (6)  the  phos- 
phate of  lime  ;  (7)  the  phosphate  of  ammonia  and  magnesia,  or 
triple  phosphate;  (8)  the  carbonate  of  lime;  (9)  the  xanthic 
or  uric  oxide  ;  ( 1  o)  the  fibrinous  ;  ( 1 1 )  the  blood  ;  (12)  the  uro- 
stealith;  and  (13)  the  silicious.  The  last  seven  being  exceedingly 
rare,  are  not  described. 

1.  The  uric  acid  calculi  are  the  most  common.  They  are  gen- 
erally of  moderate  size,  oval,  and  laterally  compressed,  of  a  nut- 
brown  color,  smooth  or  finely  granular,  moderately  heavy  and 
hard,  and  laminated  on  section.  They  are  completely  destroyed 
in  the  blow-pipe  flame,  giving  off  a  smell  of  burnt  feathers.  They 
are  insoluble  in  weak  hydrochloric  acid,  but  soluble  in  warm 
alkahes.  When  treated  by  nitric  acid  and  evaporated  to  dryness, 
on  the  addition  of  a  drop  of  ammonia  a  purple  color  is  pro- 
duced {murexide  test).  The  nucleus  is  generally  composed  of 
uric  acid,  sometimes  of  oxalate  of  lime,  and  is  generally  formed 
in  the  kidney.  These  calcuh  occur  most  frequently  m  youth  and 
middle  age. 

2.  The  oxalate  of  lime,  or  mulberry  calculi  (Figs.  327,  328), 
as  they  are  often  called  from  their  resemblance,  when  first  re- 
moved, covered  with  blood  from  the  bladder,  to  a  mulberr}%  are 
generally  of  moderate  size,  globular  in  shape,  usually  of  a  dark- 
brown  or  mahogany  color,  rough  and  tuberculated,  very  hard  and 
heavy,  and  crystalline  on  section.  They  are  only  partially  de- 
stroyed in  the  blow-pipe  flame,  the  residue  being  alkaline  and 
effervescing  with  an  acid.  They  are  insoluble  in  acetic  acid,  but 
soluble  in  hydrochloric  acid.     The  nucleus  is  generally  composed 


678 


DISEASES   OF   REGIONS. 


Oxalate  of  lime  calculus. 


Fig.  328. 


of  oxalate  of  lime,  but  may  consist  of  uric  acid  or  urate  of  am- 
monia. The  nucleus  is  usually  formed  in  the  kidney.  These  cal- 
culi are  most  frequent  in  middle  a^e. 

3.  The  phosphatic  calculi  are  of  three  kinds  :  (a)  the  phos- 
phate of  lime  or  earthy  phosphate  ;  (^)  the  ammonio-magnesian 
or  triple  phosphate,  and  (r)  the  phos- 
phate of  lime  with  the  ammonio-magne- 
sian phosphate,  the  mixed  or  fusible 
phosphate.  Of  these  the  last  is  the  only 
common  form.  It  is  usually  of  large  size 
and  of  white  color,  smooth,  soft,  friable, 
earthy  and  laminated  on  section,  and  of 
irregular  shape,  taking  that  of  the  nucleus 
on  which  it  is  formed  ;  it  fuses  when 
heated  in  the  blow-pipe  flame  ;  is  insolu- 
ble in  warm  alkalies,  but  is  soluble  in  ace- 
tic acid.  The  nucleus  is  composed  of 
uric  acid,  oxalate  of  lime,  or  of  some  for- 
eign body  other  than  a  calculus,  as  a 
piece  of  catheter,  hair-pin,  blood  or  fibrin. 
It  occurs  most  frequently  in  the  later 
p>er!ods  of  life,  and  is  then  generally  pro- 
duced as  follows  :  A  calculus  or  other  for- 
eign body  irritates  the  mucous  membrane 
of  the  bladder,  and  a  secretion  of  mucus 
is,  in  consequence,  poured  out.  This 
mucus  decomposes  the  urea  contained  in 
the  urine  into  carbonate  of  ammonia  and  water.  The  carbonate 
of  ammonia  unites  with  the  acid  phosphates,  and  an  insoluble 
mixed  phosphate  of  ammonia  magnesia  and  lime  is  thrown  down 
and  deposited  on  the  foreign  body.  Hence  these  calculi  are  only 
met  with  in  alkaline  conditions  of  the  urine. 

Although  calculi  may  be  chiefly  composed  of  one  constituent, 
they  are  more  often  composed  of  several,  which  may  be  arranged 
in  alternate  layers  {allernatini:^  calculus).  The  formation  of  these 
layers  is  due  to  the  varying  state  of  the  patient's  health  and  of  the 
condition  of  the  mucous  membrane  of  the  bladder. 


Section  of  o.xalate  of  lime 
calculus. 


DISEASES    OF   THE    H LADDER. 


Extroversion  or  ectopia  vesic/e  is  the  mnlformation  in  which, 
in  consequence  of  an  arrest  in  the  develoi)ment  of  the  anterior 
wall  of  the  bladder  and  the  corresponding  part  of  the  abdominal 
parietes,  the  posterior  wall  of  the  bladder  is  pushed  forward  by 
the  pressure  of  the  abdominal  viscera,  and  protrudes  as  a  red 


ACUTE    CYSTITIS.  679 

velvety  tumor.  It  is  associated  with  epispadias  or  absence  of  the 
upper  wall  of  the  urethra,  and  with  failure  of  union  of  the  pubic 
bones  at  the  symphysis.  The  testicles  are  frequently  retained  in 
folds  like  the  labia  on  either  side.  It  is  attended  with  extreme 
discomfort  from  the  constant  dribbling  away  of  the  urine  from 
the  mouths  of  the  ureters,  which  can  be  seen  on  the  surface  of  the 
tumor.  Treatment. — Many  operations  having  for  their  object  the 
closing  in  of  the  bladder  by  flaps  of  skin  taken  from  the  adjacent 
abdominal  wall,  have  been  performed  for  the  relief  or  cure  of  the 
deformity.  Various  attempts  have  also  been  made  to  turn  the 
ureters  into  the  colon  or  rectum,  but  without  success.  Recently 
Trendelenberg  has  succeeded  in  reducing  the  gap  between  the 
pubic  bones  by  separating  the  sacro-iliac  synchondroses,  so  that 
he  was  enabled  at  a  subsequent  sitting  to  bring  the  margins  of  the 
mucous  surface  of  the  bladder  in  contact,  and  then  unite  them  by 
a  plastic  operation.  The  newly-formed  bladder  is  in  this  way 
lined  with  mucous  membrane  instead  of  having  its  front  wall 
closed  in  by  skin.  The  objection  to  the  skin  flap  is  the  growth 
of  hair  into  the  bladder  at  puberty  and  its  incrustation  with  phos- 
phates. If  no  operation  is  undertaken  a  properly-shaped  urinal 
must  be  worn. 

Cystitis,  or  Inflammation  of  the  Bladder,  may  vary  from  the 
mildest  catarrh  to  the  most  intense  inflammation,  involving  not 
only  the  mucous  membrane  but  the  other  coats  of  the  organ  as 
well.  For  the  purpose  of  description,  however,  it  may  be  divided 
into  the  Acute  and  Chronic. 

Acute  cystitis.  Causes. — In  its  most  intense  form  it  is  nearly 
always  the  result  of  injury  or  operation,  as  the  passage  of  instru- 
ments, irritation  of  sharp  fragments  of  a  crushed  calculus,  etc.  In 
its  milder  forms  it  may  be  due  to  the  extension  of  inflammation 
from  the  urethra  as  in  gonorrhoea,  or  from  the  ureters  in  cal- 
culous pyelitis ;  to  the  exhibition  of  certain  medicines,  as 
cantharides  ;  and  occasionally  in  gouty  subjects  to  exposure  to 
cold. 

Symptoms. — In  the  acutest  forms  there  is  intense  pain,  and 
strangury,  /.  e.,  a  continual  desire  to  void  urine,  which  is  passed 
drop  by  drop  in  a  spasmodic  manner;  whilst  there  is  high  fever, 
rapidly  running  into  a  typhoid  type.  In  the  less  acute  or  more 
common  forms  micturition  is  still  very  frequent,  with  increased 
pain,  as  soon  as  a  little  urine  has  collected  in  the  bladder,  in  con- 
sequence of  the  stretching  of  the  inflamed  mucous  membrane. 
The  urine  is  scanty,  high-colored,  often  blood-stained,  and  mixed 
with  mucus  and  pus.  The  fever,  though  generally  high,  is  less 
marked  than  in  the  acuter  cases,  and  may  be  of  a  mere  transitory 
character. 


68o  DISEASES   OF   REGIONS. 

Pathology. — In  the  milder  forms  the  inflammation  is  limited  to 
the  neck  of  the  bladder  and  to  the  mucous  membrane  only.  In 
the  worst  forms  it  involves  the  whole  bladder,  and  extends  to  the 
muscular  or  even  the  peritoneal  coat.  It  may  terminate  in  i, 
resolution  ;  2,  chronic  cystitis ;  3,  ulceration  or  gangrene  of  the 
m.ucous  membrane  ;  4,  abscess  in  the  walls  of  the  bladder  ;  5,  in- 
flammation of  the  kidneys,  or  more  rarely  of  the  peritoneum ; 
and  6,  sapr^emia,  produced  by  the  absorption  of  the  products  of 
the  decomposing  urine. 

Treatvient. — The  cause,  if  possible,  should  be  removed.  Thus, 
if  there  are  fragments  of  calculus  in  the  bladder,  they  should  at 
once  be  extracted  by  the  large  evacuating  catheter,  any  that  can- 
not be  got  away  being  crushed  ;  or  perhaps  better,  the  bladder 
may  be  opened  by  a  median  incision  in  the  perineum  and  thor- 
oughly washed  out.  If  a  catheter  has  been  tied  in,  it  should  at 
once  be  withdrawn.  Hot  sitz-baths  should  be  given  night  and 
morning,  leeches  applied  to  the  perineum,  suppositories  of 
morphia  placed  in  the  rectum,  and  salicylate  of  soda,  hyoscyamus, 
and  alkalies  if  the  urine  be  acid,  administered  to  relieve  strang- 
ury. AH  stimulants  should  be  avoided,  the  diet  restricted  to 
milk,  and  the  bladder  washed  out  with  hot  water,  or  when  the 
urine  is  decomposed,  with  a  weak  antiseptic  lotion  as  boric 
acid,  salol,  etc.  If  washing  out  increases  the  irritation,  the  blad- 
der in  severe  cases  should  be  drained  by  an  incision  in  the  peri- 
neum. 

Chronic  cystitis  is  much  more  frequent  than  the  acute  variety, 
and  in  its  mildest  form  is  known  as  catarrh  of  the  bladder. 
Causes. — It  may  be  a  sequel  to  an  acute  attack ;  or  it  may  be 
chronic  from  the  commencement,  and  may  then  be  due  to  a  stone 
or  other  foreign  body  or  a  growth  in  the  bladder,  obstruction  to 
the  urinary  outflow,  as  from  an  enlarged  prostate  or  stricture  of 
the  urethra,  the  extension  of  gonorrhoea,  paralysis,  over-distension 
or  atony  of  the  bladder,  or  the  spread  of  inflammation  from  the 
neighboring  organs. 

Ihe  symptoms  are  similar  to  those  of  acute  cystitis,  but  are 
much  milder  in  intensity.  Thus,  there  is  increased  frequency  of 
micturition,  the  patient,  perhaps,  having  to  make  water  every  hour 
or  half-hour,  the  desire  to  do  so  being  generally  so  urgent  that  he 
is  unable  to  control  it.  This,  as  in  the  acute  variety,  is  due  to  the 
stretching  of  the  inflamed  mucous  membrane  as  soon  as  a  few 
ounces  of  urine  collect.  The  pain  usually  ceases  immediately 
the  bladder  is  relieved.  The  urine  is  characteristic  ;  it  generally 
contains  large  quantities  of  ropy  mucus  and  pus,  which  form,  on 
standing,  a  distinct  layer  at  the  bottom  of  the  containing  vessel. 
It  is  often  alkaline,  and  sometimes  highly  ammoniacal  and  offen- 


ANTONY    AND    PARALYSIS    OF    THE    BLADDER.  68 1 

sive  from  the  decomposition  of  the  urea  into  carbonate  of  ammo- 
nia. This  decomposition  is  brought  about  by  fermentation,  prob- 
ably set  up  by  the  presence  of  micro-organisms  {micrococcus  uircz) 
that  have  gained  admission  either  by  the  use  of  a  contaminated 
catheter,  or  by  making  their  way  along  the  stringy  mucus  that 
may  hang  about  the  urethra.  Pathology. — The  mucous  membrane 
is  thickened,  velvety,  mottled  with  patches  of  a  dark  slate  or  red 
color,  and  may  be  covered  with  muco-pus  and  sometimes  with  a 
deposit  of  phosphates,  or  it  may  even,  in  places,  be  destroyed  by 
ulceration.  The  muscular  coat,  where  there  has  been  obstruction 
to  the  outflow,  becomes  thickened  and  fasciculated,  the  hyper- 
trophied  fibres  giving  the  interior  of  the  bladder  a  columnar  and 
rugose  appearance.  In  places  the  mucous  membrane  may  pro- 
trude between  the  fasciculi  of  the  muscular  coat,  forming  sacculi 
which  may  become  receptacles  for  urine,  and  in  which  calculi  may 
form.  If  the  cystitis  is  allowed  to  continue  the  kidneys  may  sub- 
sequently become  affected. 

Treatment. — As  in  the  acute  form  the  cause,  as  stricture,  stone, 
etc.,  must  first  be  removed,  as  where  this  is  impracticable  the  treat- 
ment at  best  can  only  be  palliative.  The  diet  should  be  unstim- 
ulating,  and  alcohol  in  any  form,  as  a  rule,  forbidden.  A  purely 
milk  diet  is  at  times  most  successful.  Internally  such  medicines 
as  buchu,  uva  ursi,  balsam  of  copaiva,  salol  and  chlorate  of  potash 
should  be  given  where  thick  ropy  mucus  is  passed  with  the  urine  ; 
and  benzoic  acid,  which  in  its  passage  through  the  system  is  con- 
verted into  hippuric  acid,  may  be  tried  when  the  urine  is  alkaline. 
Locally,  the  bladder  should  be  washed  out  twice  a  day  with  some 
antiseptic  solution,  as  boric  acid,  nitric  acid,  corrosive  sublimate, 
quinine,  etc.  The  best  results  are  sometimes  obtained  from  water 
as  hot  as  can  be  borne.  Great  care  should  be  taken  that  all 
instruments  are  rendered  thoroughly  aseptic  before  use.  In 
severe  cases,  where  other  means  have  failed,  the  bladder  should 
be  placed  at  rest  by  perineal  cystotomy  and  subsequent  drainage 
for  some  weeks. 

Irritaf.iiity  of  the  bladder,  by  which  is  meant  a  too  frequent 
passing  of  water,  is  often  spoken  of  as  a  disease ;  but  is  no  more 
so  than  is  pain,  since  it  is  is  only  a  symptom  either  of  disease  of 
the  urinary  organs,  or  of  some  general  state  of  the  system,  as 
hysteria,  Bright's  disease,  etc.  The  cause  should  be  sought  and 
treated. 

Inversion  of  the  bladder,  and  hernia  of  the  bladder,  are  both 
very  rare,  and  are  not  here  described. 

Atony  and  paralysis  of  the  bladder.  Both  these  terms  are 
applied  to  a  want  of  sufficient  contractile  power  in  the  muscular 
coat  to  expel  the  contents  of  the  bladder  ;  but  in  atony  the  want  of 


682  DISE.ASES   OF   REGIONS. 

power  is  the  result  of  loss  of  tone  in  the  muscular  fibres,  while 
paj-alysis  is  due  to  the  failure  of  nervous  influence.  Eoth  condi- 
tions must  be  distmguished  from  the  mere  inability  of  the  blad- 
der to  empty  itself  on  account  of  obstruction  to  its  outlet.  (See 
Retention,') 

Atony  may  be  due  to — i.  Simple  over-distension,  consequent 
upon  the  patient  having  voluntarily  or  compulsorily  held  his  urine 
for  too  long  a  period,  whereby  the  muscular  fibres  are  over- 
stretched and  unable  to  recover  themselves.  2.  It  may  be  the 
result  of  gradual  distension  owing  to  enlarged  prostate  or  stric- 
ture. In  consequence  of  the  obstruction,  the  bladder  does  not 
empty  itself,  but  some  urine  remains  after  every  act  of  micturi- 
tion ;  the  amount  retained  gradually  increases,  the  bladder  be- 
comes distended,  and  its  fibres,  if  the  patient  is  old,  become 
stretched,  and  lose  their  tone,  instead  of  becoming  hypertrophied, 
as  commonly  happens  in  a  young  and  healthy  person.  3.  Again, 
atony  may  be  due  to  cystitis,  owing  to  the  inflammation  having 
spread  to  the  muscular  coat,  which  then  undergoes  fibroid  or  fatty 
changes. 

Symptoms. — The  patient  complains  of  inability  to  hold  his 
urine,  or  that  it  constantly  dribbles  away,  or  that  he  has  to  pass  it 
very  frequently.  The  involuntary  flow  occurs  at  first  during 
sleep ;  afterwards  on  any  exertion  causing  contraction  of  the 
abdominal  muscles.  These  symptoms,  although  often  improperly 
spoken  of  as  incontinence,  are  really  those  of  retention,  the  blad- 
der being  fully  distended,  but  unable  to  empty  itself,  and  the  ex- 
cess flowing  involuntarily  away. 

The  treatment  consists  in  passing  a  catheter  at  regular  inter- 
vals, and  as  often  as  may  be  necessary  to  completely  empty  the 
bladder;  whilst,  in  the  meantime,  the  condition  leading  to  the 
atony  must  be  treated  by  appropriate  means.  Thus,  if  the  result 
of  over-distension,  strychnine  and  galvanism  may  be  tried  ;  if  the 
result  of  gradual  distension  from  enlarged  prostate  or  stricture, 
these  conditions  must  be  treated  in  the  way  mentioned  under 
their  respective  heads.  In  both  paralysis  and  atony,  cystitis, 
dilatation  of  the  ureters,  pyelitis  and  disorganization  of  the 
kidney  rapidly  ensue  if  the  cause  of  the  bladder  trouble  cannot 
be  relieved. 

True  paralysis  of  the  bladder  is  nearly  always  the  result  of 
disease  or  injury  of  the  brain  or  spinal  cord,  and  is  not  met 
with  except  in  general  paralysis.  'J'he  bladder  being  paralyzed 
cannot  empty  itself,  and  becomes  distended  as  in  atony  ;  and 
when  it  can  hold  no  more,  the  excess  overflows  through  the 
sphincter,  which  is  also  j)aralyzecl.  Rejlex  paralysis,  however, 
often  occurs  after  an  injury  or  surgical  operation,  especially  that 


THE    TUMORS    MET    IN   THE    BLADDER.  683 

for  haemorrhoids.  The  local  treaiment  consists  in  the  regular 
passage  of  a  catheter  two  or  three  times  daily. 

Tubercle  of  the  bladder  is  rare,  and  is  nearly  always 
secondary  to  tubercle  in  other  parts  of  the  genito-urinary  tract. 
There  is  pain,  haemorrhage,  and  other  signs  of  chronic  cystitis ; 
but  the  diagnosis  will  depend  rather  on  the  exclusion  of  other 
diseases  such  as  stone,  tumors,  etc.,  and  the  presence  of  tubercle 
in  other  organs.  Treatment. — The  general  constitutional  reme- 
dies for  tubercle  should  be  employed ;  together  with  such  local 
remedies  as  are  indicated  for  cystitis,  and  for  the  assuaging  of  the 
pain.  These  failing  to  relieve,  suprapubic  cystotomy  may  be 
done  and  the  bladder  washed  out,  and  such  caseous  masses  of 
tubercle  as  permit  of  it  scraped  away. 

Vesico-intestfnal  fistula  may  be  known  by  the  occasional 
passage  of  faecal  matter  and  gas  by  the  urethra,  and  is  usually  a 
source  of  great  discomfort.  It  commonly  depends  on  inflammatory 
or  other  form  of  ulceration  of  the  intestine  involving  the  bladder. 
Treatment. — When  the  fistula  is  thought  to  be  low  down  the 
intestine  the  abdomen  may  be  explored,  and  the  colon  above  the 
fistula  united  to  the  abdominal  wall  and  then  opened. 

The  tumors  that  may  be  met  with  in  the  bladder  are  : — i. 
Thefihi-ous.  2.  The  mucous.  3.  The  villous  or  papillomatous.  4. 
The  tjialignant.  The  fibrous  and  mucous  spring  from  the  sub- 
mucous coat,  and  protruding  the  mucous  membrane  in  front  of 
them  assume  a  polypoid  or  warty  shape.  They  are  very  rare. 
The  villous  or  papillomatous  spring  from  the  mucous  membrane, 
and  appear  as  soft,  flocculent  growths  resembling  the  villi  of  the 
chorion.  They  are  the  most  common  of  the  innocent  growths. 
The  malignant  either  spring  from  the  mucous  or  the  sub- mucous 
coat,  and  may  form  a  large  mass  often  nearly  filling  the  bladder, 
or  assume  a  villous  appearance,  or  merely  infiltrate  the  walls. 
They  have  either  a  carcinomatous  or  sarcomatous  structure. 

The  symptoms  common  to  all  are  those  of  a  foreign  body  in  the 
bladder,  with  haematuria  and  absence  on  sounding  of  stone.  In 
Xhtfil^rous  there  are  signs  of  obstruction  to  the  urinary  outlet,  but 
little  or  no  haematuria,  and  the  tumor  may  sometimes  be  felt 
with  the  sound.  In  the  villous  (Fig.  329)  there  is  usually  more 
or  less  continuous  haemorrhage,  without  any  other  cause  being 
discoverable  to  account  for  it ;  there  is  seldom  any  marked  ob- 
struction to  the  urinary  outflow ;  and  shreds  of  the  growth  may 
come  away  spontaneously  or  in  the  eye  of  the  catheter.  In  the 
malignant  there  are  usually  sudden  attacks  of  severe  haemorrhage 
from  time  to  time  ;  and  a  growth  may  be  felt  by  the  sound,  or  by 
the  finger  in  the  rectum,  or  by  palpation  above  the  pubes.  There 
are    commonly    moreover    other    signs    of  malignancy,  as  rapid 


684 


DISEASES   OF   REGIONS. 


growth  of  the  tumor,  cachexia,  etc.  Tumors  of  the  bladder, 
however,  especially  the  villous,  are  often  difficult  to  diagnose  ; 
some  aid,  it  is  tnie,  may  at  times  be  gained  by  the  electric 
cystoscope,  but  a  diagnosis  cannot  always  be  made  without  a 
digital  exploration  of  the  bladder,  which  should  be  undertaken 
where  symptoms  such  as  the  above  are  persistent  unless  they 
point  to  a  malignant  growth.  In  using  the  cystoscope  a  meas- 
ured quantity  of  fluid  should  be  left  in  the  bladder,  which  should 

be    previously    irrigated    if 
F'G-  329.  the  urine  contains  blood  or 

pus   till    the    fluid    returns 
clear. 

Treatment. — The  removal 
of  the  tumor,  except  it  is 
malignant,  should  generally 
be  attempted.  In  the  fe- 
male the  urethera  may  be 
dilated  for  this  purpose.  In 
the  male  the  incision  into 
the  bladder  should  be  made 
above  the  pubes,  and  the 
site  of  the  tumor  lighted  up 
by  passing  a  large  glass 
vaginal  speculum  into  the 
bladder  so  that  the  tumor 
may  lie  included  in  its  lumen. 
If  more  light  is  required  a 
small  electric  lamp  on  a 
slender  handle  can  be  passed  down  the  speculum.  The  growth 
may  be  then  removed  by  the  cold  wire  or  galvano-cautery  loop, 
or  by  forceps,  or  be  burned  off  by  the  actual  or  galvano-cautery. 
If  a  villous  tumor  is  simply  torn  off  by  forceps,  severe  haemorrhage, 
which  I  have  known  to  prove  uncontrollable  and  end  fatally,  may 
ensue.  Tumors  infiltrating  the  anterior  wall,  if  not  too  large, 
may  be  removed  by  raising  the  peritoneum,  excising  the  growth 
with  the  infiltrated  wall,  and  uniting  the  edges  of  the  wound  with 
sutures.  When  removal  is  contra-indicated,  relief  where  there  is 
obstruction  to  the  urinary  outlet  may  be  obtained  by  suprapubic 
puncture  ;  haemorrhage  should  be  restrained  by  astringents ;  and 
pain  assuaged  by  opium. 

SiON'E  IN  THK  lii.ADDKR  may  occur  at  any  age,  but  it  is  said  to 
be  most  frequent  between  the  ages  of  fifty  and  seventy  ;  next,  be- 
tween the  ages  of  two  and  six ;  whilst  between  the  ages  of 
twenty-six  and  thirty-six  it  is  rare.  It  may  occur  in  both  males 
and  females,  but  is  decidedly  more  common  in  tlie  former. 


Villous   tumor    of   the    bladder.      (St.    Biinhnlo 
mew's  Hospital  Museum.) 


STONE    IN   THE    BLADDER.  685 

The  causes  are  not  altogether  known  ;  but  residence  in  certain 
districts  or  countries,  poor  living,  abuse  of  alcohol,  especially  in 
the  form  of  malt  liquor,  excess  of  nitrogenuous  food,  want  of  suf- 
ficient exercise,  and  anything  that  induces  the  excessive  formation 
of  uric  or  oxahc  acid  in  the  urine,  are  regarded  as  predisposing 
causes.  Retention  of  urine  from  prostatic  enlargement  and  the 
presence  of  a  foreign  body  in  the  bladder  are  exciting  causes.  In 
a  few  cases  a  nucleus  has  been  formed  for  a  calculus  by  a  piece 
of  necrosed  bone  which  has  reached  the  bladder  from  a  fractured 
pelvis  or  carious  spine. 

Varieties.— Tht  three  most  common  varieties  of  calcuH  met 
with  in  the  bladder  are  the  uric  acid,  the  oxalate  of  hme,  and  the 
phosphatic.  They  may  occur  almost  pure  or  they  may  be  mixed. 
According  to  Sir  Henry  Thompson  the  uric  acid  and  urates  form 
one-half  of  the  number  met  with ;  the  phosphatic  one  quarter ; 
the  mixed,  one  quarter;  and  the  oxalates  only  three  per  cent,  of 
the  whole.  The  uric  acid  and  the  oxalate  of  lime  are  generally 
formed  on  a  nucleus  of  one  of  these  substances  which  has  de- 
scended from  the  kidney.  The  phosphatic  is  formed  in  the 
bladder  itself,  either  on  a  nucleus  of  phosphates  deposited  on 
some  inspissated  mucus  or  a  foreign  body,  or  on  one  of  the  other 
forms  of  stone  which  has  descended  from  the  kidney,  and  which, 
sooner  or  later  acts  as  a  foreign  body.  The  oxalate  of  lime  is  the 
most  slow  of  formation,  and  is  consequently  the  hardest  and 
most  compact.  The  phosphatic  forms  very  rapidly,  is  soft  and 
friable,  and  often  of  very  large  size.  Sometimes  alternate  layers 
of  uric  acid  oxalate  of  lime,  and  phosphates  occur  in  the  same  stone 
{^alternating  calatlus),  a  condition  probably  due  to  varying  states 
of  the  patient's  health,  effects  of  medicines,  bladder  irritation, 
etc.  A  description  of  the  various  forms  of  calculi  is  given  in  the 
section  on  Urinary  Calculi  (page  677). 

The  character  of  the  stone  may  to  some  extent  be  guessed  at 
by  the  state  of  the  urine.  Thus,  if  the  urine  is  acid,  it  will  prob- 
ably be  either  oxalate  of  lime  or  uric  acid ;  if  alkaline,  phos- 
phatic. Calculi  vary  in  size  from  that  of  a  hemp-seed  to  a 
large  mass  weighing  many  ounces ;  but  large  stones  at  the  pres- 
ent day,  in  consequence  of  improved  diagnosis  and  the  dimin- 
ished dread  a  patient  has  of  an  operation,  are  the  exception. 
They  generally  occur  singly,  but  there  may  be  two,  or  even 
more  ;  they  are  then  usually  faceted  from  rubbing  against  one 
another. 

Spontaneotis  fracture  sometimes  happens,  and  has  been  attrib- 
uted :  I,  to  the  swelling  or  chemical  alteration  of  the  cementing 
material  with  which  the  particles  of  the  calculus  are  held  to- 
gether;  2,  to  two  stones  coming  into  collision;  3,  to  the  com- 


686  DISEASES   OF   REGIONS. 

pression  of  the  calculi  by  the  hypertrophied  muscular  coat  of  the 
bladder. 

The  calculus  may  be  variously  situated  in  the  bladder.  It  is 
usually  free  just  behind  the  prostate,  but  it  may  be  in  the  upper 
fundus  behind  the  pubes,  or  in  one  of  the  sacculi  so  often  found  in 
long-standing  diseases  of  the  bladder  (encysted).  Calculous 
matter  may  sometimes  be  deposited  upon  growths  in  the  bladder 
or  upon  the  ulcerated  mucous  membrane. 

The  terminations  of  stone. — If  neglected,  cystitis  is  set  up,  and 
inflammation  may  spread  up  the  ureters  to  the  kidneys,  leading 
to  the  changes  described  under  Suro^ical  Diseases  of  the  Kidneys. 
In  consequence,  moreover,  of  the  obstruction  to  the  urinary  out- 
let, the  bladder  may  become  hypertrophied,  and  the  ureters  and 
kidneys  dilated  in  the  way  described  under  strictu?-e. 

Symptoms. — The  three  chief  symptoms  are — i.  Pain,  generally 
referred  to  the  end  of  the  penis,  and  worse  after  micturition  on 
account  of  the  stone  then  falling  on  the  sensitive  trigone  and  the 
walls  of  the  bladder  contracting  upon  it.  2.  Frequent  micturi- 
tion ;  and,  3.  A  little  blood  in  the  urine.  These  symptoms  are 
increased  on  exercise,  especially  riding,  and  after  the  jolting  of  a 
railway  journey,  etc.,  and  are  least  marked  at  night  when  the  pa- 
tient is  at  rest.  Other  symytoms  that  may  be  present  are  the 
passage  of  gravel ;  sudden  stoppage  of  the  stream  during  mictur- 
ition ;  the  presence  of  muco-pus  in  the  urine  owing  to  cystitis  ; 
piles  in  adults  and  prolapse  of  the  rectum  in  children,  due  to 
straining  ;  and  elongation  of  the  prepuce  in  boys,  caused  by  the 
constant  handling  to  relieve  pain  after  micturition.  Stone  in  the 
bladder  may  be  simulated  by  cystitis,  an  enlarged  prostate,  a  long 
or  adherent  prepuce,  a  narrow  meatus,  a  growth  in  the  bladder, 
calculous  or  other  disease  of  the  kidney,  a  peculiar  choreic  con- 
dition of  the  bladder  (the  stammering  bladder  of  Sir  James 
Paget),  tubercle  of  the  bladder,  and  ascarides  in  the  rectum.  An 
accurate  diagnosis,  however,  can  only  be  made  by  sounding  the 
bladder ;  though  in  boys  the  stone  may  be  felt  by  the  finger  in 
the  rectum  whilst  pressure  is  made  with  the  other  hand  above  the 
pubes. 

Sounding:;  the  bladder. — I'he  ordinary  sound  (Fig.  330)  is  a  solid 
steel  instrument  with  a  short  bulbous  beak.  Thompson's  sound  is 
hollow  to  allow  some  of  the  urine  to  be  drawn  off  if  desired,  and 
has  a  handle  like  that  of  his  lithotrite,  to  facilitate  the  necessary 
movements  in  the  bladder.  Having  warmed  and  oiled  the  sound, 
pass  it  like  a  catheter,  letting  it  glide  into  the  bladder  by  its  own 
weight  without  using  any  force.  When  the  sound  is  in,  gently 
push  it  onwards  to  examine  the  posterior  part  of  the  bladder. 
Then   turn  the  beak  alternately  to   either  side  ;  and  depress  the 


STONE    IN   THE    BL.A.DDER.  687 

handle  between  the  patient's  thighs  to  search  the  upper  fundus. 
Then  turn  the  beak  downwards  to  examine  the  base  or  lower 
fundus.  If  the  stone  is  not  detected,  let  out  a  httle  of  the  urine, 
or  change  the  patient's  position,  or  raise  his  pelvis  and  try  again. 

Fig.  330. 


Ordinary  sound. 

The  stone  may  not  be  felt,  because  it  is  of  small  size,  or  has  be- 
come encysted,  or  entangled  in  a  fold  of  mucous  membrane.  A 
guarded  opinion,  therefore,  should  be  given,  and  a  further  ex- 
amination made  another  day.  A  stone  may  be  known  to  be 
present  by  the  peculiar  ring  which  is  both  felt  and  heard  on  strik- 
ing it.  This  ring  is  quite  unlike  the  sensation  given  to  the  sound 
by  its  coming  into  contact  with  phosphatic  deposits  on  a  rough- 
ened or  fasciculated  bladder,  or  with  one  of  the  pelvic  bones. 
Having  discovered  a  stone,  the  next  care  should  be  to  determine 
approximately — i,  its  probable  size  and  composition;  2,  whether 
it  is  free  or  encysted ;  3,  whether  there  is  one  stone  or  more ; 
and,  4,  the  condition  of  the  bladder  and  urethra,  i.  The  size 
of  the  stone  can  be  roughly  estimated  by  the  amount  of  resistance 
offered  on  pushing  it  before  the  sound  or  by  passing  the  sound 
over  it,  and  by  feeling  it  through  the  rectum  with  the  other  hand 
pressing  on  the  hypogastrium.  Its  exact  size  can  only  be  ascer- 
tained by  seizing  it  with  the  lithotrite,  the  distance  the  blades 
are  then  apart  being  indicated  by  the  scale  on  the  handle.  The 
composition  of  the  stone  may  be  approximately  arrived  at  by  {a) 
the  character  of  the  ring  on  striking  it — the  clearer  the  ring  the 
harder  the  stone,  {b)  the  condition  of  the  surface,  which  is  rough 
in  the  oxalate  of  lime,  smooth  in  the  phosphatic,  {c)  the  re-action 
of  the  urine,  and  {d),  the  general  health  of  the  patient.  2.  A 
stone,  when  encysted,  is  always  felt  at  the  same  spot  in  the  bladder, 
and  when  seized  with  the  lithotrite  cannot  be  moved.  The  sound 
cannot  be  passed  all  round  it.  There  is  no  blood  present,  and 
the  symptoms  are  usually  less  severe,  and  are  not  increased  by 
exercise.  3.  The  presence  of  a  second  stone  can  only  be  de- 
termined with  certainty  by  seizing  one  stone  with  the  lithotrite, 
and  then  striking  the  other. 

Treatment. — The  stone  may  be  removed  by  crushing  {lithotrity), 
or  cutting  {lithotomy).  In  adults,  lithotrity,  with  but  few  excep- 
tions, should  be  the  rule.  In  children,  up  to  twelve  or  fourteen 
years  of  age,  lithotomy  has  hitherto  been  the  recognized  opera- 


688  DISEASES   OF   REGIONS. 

tion  ;  but  I  believe  that  when  the  brilHant  results  obtained  by 
Surgeon-]\Iajor  Keegan  and  others  come  to  be  better  known,  that 
even  in  very  young  children,  lithotrity,  as  in  adults,  will  also  be 
the  rule,  lithotomy  the  exception.  I  have  myself  crushed  six  or 
seven  stones  in  young  male  children,  some  as  young  as  three 
years,  and  successful  cases  are  now  being  frequently  reported. 
In  adults,  lithotomy  should  be  practised  in  place  of  lithotrity, 
when  1,  the  stone  is  very  large  and  hard  ;  2,  when  the  urethra  is 
the  seat  of  intractable  stricture ;  3,  when  the  stone  is  encysted ; 
and,  4,  when  the  bladder  is  sacculated.  A  large  stone,  if  soft, 
should  be  crushed ;  and  a  hard  stone,  if  not  too  large,  is  no  bar 
to  the  operation.  Surgeon- Major  Keegan  has  crushed  a  uric  acid 
stone,  the  fragments  of  which  weighed  two  ounces  and  three 
quarters,  and  an  oxalate  of  lime  which  weighed  one  ounce  and 
three  drachms.  And  in  a  boy,  aged  thirteen,  I  crushed  and  suc- 
cessfully removed  a  very  hard  stone  weighing  only  a  few  grains 
less  than  an  ounce.  Hard  stones,  however,  weighing  above  an 
dunce,  and  especially  in  boys,  had  better  be  removed  by  cutting, 
unless  the  Surgeon  is  experienced  in  lithotrity.  Cystitis  and 
kidney  disease  render  the  prognosis  of  both  operations  unfavor- 
able ;  but  in  these  affections  it  does  not  appear  that  crushing  with 
complete  removal  of  the  fragments  is  attended  with  more  risk 
than  is  lithotomy.  A  large  prostate  renders  lithotrity  difficult  no 
doubt,  but  does  not,  as  a  rule,  contra-indicate  it.  Stricture  of  the 
urethra  is  only  an  impediment  to  lithotrity  when  the  stricture  can- 
not be  dilated.  The  conditions,  however,  most  favorable  for  suc- 
cess in  lithotrity  are,  as  well  expressed  by  Sir  Henry  Thompson, 
"a  capacious  urethra,  a  bladder  capable  of  retaining  three  or  four 
ounces  of  urine,  absence  of  ordinary  signs  of  renal  disease,  and 
fair  general  health." 

LnHOiRiTV,  LiTHOLAPAXY,  or  BiGELOw's  OPERATION  consists  in 
crushing  the  stone  in  the  bladder,  and  removing  the  ivhole  of  the 
fragments  through  a  large  evacuating  catheter.  Formerly,  it  was 
taught  that  the  presence  of  the  lithotrite  in  the  bladder  for  more 
than  a  few  minutes  at  a  time  was  productive  of  great  irritation, 
and  it  was  consequently  advised  that  the  crushing  of  the  stone 
should  be  extended  over  several  sittings  of  only  a  few  minutes 
each,  and  the  fragments  allowed  to  be  passed  by  the  natural 
efforts  of  the  patient.  To  the  late  Professor  Bigeluw  is  un- 
doubtedly due  the  credit  of  having  enunciated  the  principle  that 
the  bladder  is  not  so  intolerant  of  instruments  as  was  formerly 
supposed,  and  that  it  was  to  the  presence  of  the  fragments,  rather 
than  to  the  lithotrite,  that  the  irritation,  cystitis,  etc.,  so  common 
after  the  old  method,  should  be  ascribed. 

The  operation. — The  patient,  having  been  prepared  for  the  opera- 


LITHOTRITY,  LITHOLAPAXY,  OR    BIGELOW'S    OPERATION.  689 

tion  by  careful  attention  to  the  general  health,  rest,  and  such  local 
means  for  allaying  chronic  cystitis  as  were  pointed  out  under  that 
head,  should  be  placed  under  an  anaesthetic,  with  the  pelvis  raised 
a  few  inches,  the  thighs  slightly  apart,  the  knees  supported  on  a 
pillow,  and  the  body  and  legs  well  wrapped  up  in  blankets  to  avoid 
a  chill.  The  rectum  should  be  emptied  by  a  purge  the  day  before, 
and  by  an  enema  on  the  morning  of  the  operation.  A  few  ounces 
of  urine  in  the  bladder  is  desirable.  If  necessary,  incise  the 
meatus  (a  stricture,  if  present,  should  have  previously  been  di- 
lated), warm  and  oil  the  lithotrite  (Fig.  331),  and  pass  it  with  all 


Fig.  331. 


Thompson's  lithotrite. 

gentleness,  letting  it  glide  by  its  own  weight  through  the  spongy 
and  membraneous  portion  of  the  urethra,  and  do  not  depress  the 
handle  till  the  blades  have  reached  the  prostate.  Then  bring  the 
shaft  to  an  angle  of  35°  with  the  horizon,  and  it  will  ghde  through 

Fig.  332. 


Lithotrite  in  situ.     (Listen's  Surgery.) 

the  prostatic  urethra,  over  the  trigone  of  the  bladder,  and  may 
possibly  be  felt  to  graze  the  stone.     The  blades  now  rest  in  the 
lowest  part  of  the  bladder  and  point  upwards  (Fig.  332).     Hold. 
29* 


690 


DISEASES   OF   REGIONS. 


the  handle  tightly  with  the  left  hand,  and,  without  moving  the  in- 
strument, open  the  male  blade  by  drawing  out  the  wheel-shaped 
end  with  the  right  hand.  Pause  a  few  seconds  to  allow  the  cur- 
rents set  up  in  the  urine  by  this  movement  to  subside.  Then 
gently  press  in  the  male  blade,  and  the  stone  will  probably  be 
caught.  If  so,  continue  the  pressure  on  the  wheel  to  retain  the 
stone  between  the  blades,  whilst  the  button  is  moved  by  the 
thumb  to  convert  the  sliding  into  the  screw  movement.  Rotate 
the  instrument  slightly  to  make  sure  that  the  mucous  membrane 
is  not  caught  by  the  blades  ;  slightly  depress  the  handle  to  raise 
the  blades  from  the  walls  of  the  bladder,  and  screw  home.  The 
stone  will  probably  be  felt  to  crack  and  break  into  fragments.  If 
the  stone  cannot  be  seized  in  this  way,  systematically  explore  the 
bladder  thus  : — Open  the  blades  and  rotate  45  degrees  ;  pause 
and  close.  Do  this  first  to  the  right,  then  to  the  left.  Then  raise 
the  blades  slightly  by  depressing  the  handle ;  rotate  alternately  to 
right  and  left  90  degrees;  further  raise  the  blades  and  rotate  135 
degrees.  Finally,  reverse  the  blades  by  rotating  half  a  circle.  In 
this  way  the  stone  will  probably  be  found.  In  these  manoeuvres 
the  blades  should  be  opened  before  rotating  them  in  order  that 
the  stone  may  not  be  displaced  by  the  male  blade,  and  after 
rotating  a  pause  should  be  made  before  closing  them  to  allow  the 
currents  to  subside.  Having  crushed  the  stone  and  larger  frag- 
ments, withdraw  the  lithotrite,  first  screwing  tight  home  to  en- 
sure complete  closure  of  the  blades  in  order  to  prevent  laceration 
of  the  urethra.  Next  introduce  a  large  evacuating  catheter  (No. 
16,  or  larger)  ;  let  the  urine  escape  and  inject  two  or  three  ounces 
of   warm    water.     Attach    the   aspirator,    previously   filled   with 

water  at  a  temperature  of  98°,  and 
compress  the  india-rubber  bulb, 
driving  some  of  the  water  into  the 
bladder.  Let  the  bulb  expand  and 
the  outward  current  will  bring  away 
some  of  the  fragments  and  debris, 
which  will  fall  into  the  receiver  and 
be  ])revented  from  returning  into 
the  bladder  by  the  trap  (see  Fig. 
333)  on  again  compressing  the 
bull).  Continue  compressing  and 
relaxing  till  fragments  cease  to 
come  away.  Then  if  any  are  felt 
by  the  evacuating  catheter  le-introduce  the  lithotrite,  or  a  smaller 
one,  and  crush  again  and  aspirate  as  before,  repeating  this  till  all 
the  fragments  are  j-emoved.  The  operation  frequently  lasts  for  an 
hour  to  an  hour  and  a  half  or  longer. 


Fig.  333. 


Thompson's  improved  cvaciuitor 
and  trap. 


LATERAL  LITHOTOMY.  69 1 

Afte7'-treatmcnt. — Opium,  if  no  serious  kidney  disease  is  present, 
may  be  given  ;  and  hot  hip-baths  if  there  is  much  pain.  If  there 
is  retention  the  catheter  should  be  used  at  regular  times,  or  tied 
in  if  its  passage  causes  much  irritation  and  pain.  Complete  rest 
in  bed  for  a  few  days  or  longer  should  be  enjoined.  If  cystitis 
follows  the  operation,  Sir  Henry  Thompson  strongly  recommends 
a  weak  injection  of  silver  nitrate  (gr.  i  to  f.si.).  As  a  rule,  how- 
ever, I  have  found  no  after-treatment  required,  even  in  young 
boys.  Indeed,  in  several  cases  the  child  has  been  up  and  play- 
ing about  the  ward  the  day  after  the  operation. 

Afte}--  complications. — i.  Rigors  and  fever;  2,  retention  of  urine  ; 
3,  acute  cystitis;  4,  prostatitis  and  abscess,  and  5,  orchitis  and 
epididymitis,  occasionally  occur.  More  rarely,  6,  haemorrhage;  7, 
suppression  of  urine,  and  8,  phlebitis  of  the  prostatic  plexus  of 
veins,  followed  by  pyaemia.  The  impaction  of  a  fragment  of  the 
calculus  in  the  urethra  (formerly  common  when  the  fragments 
were  left  in  the  bladder)  cannot  occur  if  the  bladder  has  been 
thoroughly  evacuated. 

Causes  of  death. — Death  may  occur  from  i.  Acute  nephritis  ;  2. 
Pyelitis;  3.  Cystitis;  4.  Perforation  or  rupture  of  the  bladder;  5. 
Peritonitis;  6.  Saproemia  or  pysemia;  or  7.  Exhaustion.  But  a 
fatal  termination  is  rare  except  where  there  is  some  chronic 
kidney  disease. 

LiTHOTOiviY,  or  cutting  for  the  stone,  may  be  performed  through 
the  perineum  or  above  the  pubes.  Perineal  lithotomy  may  be  done 
in  many  ways ;  the  lateral,  as  usually  performed,  and  the  median, 
will  only  be  described.  •• 

Lateral  lithotomy. — The  patient  should  be  prepared  by  rest 
in  bed  for  a  few  days,  and  the  rectum  cleared  by  a  mild  purgative 
the  day  before,  and  by  an  enema  on  the  morning  of  the  operation. 
The  bladder  should  contain  five  or  six  ounces  of  urine,  or  if  the 
patient  is  unable  to  retain  so  much,  an  equal  quantity  of  warm 
water  should  be  injected.  Anesthetize  the  patient,  introduce  a 
full-sized  staff  with  a  groove  on  the  left  side  into  the  bladder,  and 
try  to  strike  the  stone.  If  the  stone  is  not  felt,  withdraw  the  staff 
and  pass  a  sound.  If  still  unsuccessful,  send  the  patient  back  to 
bed,  as  the  stone  may  have  been  passed  per  urethram  or  become 
encysted.  If  felt  by  the  sound,  re-introduce  the  staff,  but  do  not 
operate  until  the  staff  itself  strikes  the  stone,  that  you  may  be  sure 
that  the  staff  has  passed  into  the  bladder,  and  not  into  a  false  pass- 
age. It  is  usual  to  ask  an  assistant  to  strike  the  stone  also.  Next 
place  the  patient  in  the  lithotomy  position,  /.  e.,  with  the  soles  of 
the  feet  secured  in  the  p'.ilms  of  the  hands  by  the  lithotomy 
shackles,  and  bring  his  nates  well  over  the  end  of  the  table. 
Entrust  the  staff  to  an  assistant,  who  should  hold  it  perpendicu- 


692 


DISEASES   or   REGIONS. 


larly,  with  its  concavity  hooked  well  up  under  the  pubes  and  ex- 
actly in  the  middle  line.  Seat  yourself  in  front  of  the  patient,  and 
having  introduced  the  left  forefinger  into  the  rectum  to  make  sure 
that  it  is  empty,  and  to  induce  it  to  contract,  enter  the  knife  (Fig. 
334),  which  should  be  held  horizontally,  a  little  to  the  left  of  the 
middle  line  and  about  an  inch  and  a  quarter  in  front  of  the  verge 
of  the  anus,  and  carry  the  incision  downwards  and  to  the  left,  to 

Fig.  334. 


Lithotomy  knife. 

a  point  one-third  nearer  to  the  tuberosity  of  the  ischium  than  to 
the  margin  of  the  anus.  Pass  the  left  forefinger  into  the  upper 
angle  of  the  wound  and  feel  for  the  staff;  divide  with  the  knife 
the  superimposed  tissues ;  insert  the  finger-nail  into  the  groove  in 
the  staff,  the  back  of  the  finger  being  to  the  patient's  left ;  and 
guided  by  the  nail,  press  the  point  of  the  knife  into  the  groove  just 

Fig.  335- 


Parts  cut  in  lithotomy.     (Ferguson's  .Surgery.) 

in  front  of  the  membraneous  portion  of  the  urethra  (Fig  335). 
Now  run  the  knife  with  the  i)oint  pressed  firmly  in  the  groove 
onwards  into  the  bladder,  keeping  its  blade  well  lateralized,  i.  e., 


LATERAL   LITHOTOMY. 


693 


Fig.  ^36. 


directed  downwards  and  to  the  left.  Take  care  not  to  depress  the 
handle  too  much  for  fear  of  cutting  the  prostate  too  widely,  nor 
to  hold  it  too  horizontal  lest  the  point  slip  out  of  the  groove  and 
penetrate  the  tissues  between  the  bladder  and  the  rectum.  Having 
entered  the  bladder,  shghtly  enlarge  the  wound  in  the  prostate  in 
withdrawing  the  knife,  and  pass  the  left  forefinger,  which  is  in  the 
wound,  onwards  along  the  staff  into  the  bladder.  If  the  stone  is 
felt  by  the  finger,  ask  the  assistant  to  withdraw  the  staff.  Take 
the  forceps  in  the  right  hand,  pass  them  along  the  left  forefinger 
towards  the  bladder,  and,  on  with- 
drawing the  finger,  open  the  blades, 
and  the  stone  will  probably  be  driven 
by  the  gush  of  urine  between  them. 
Having  assured  yourself  that  the  stone 
is  grasped  by  the  forceps  in  its  smallest 
diameter,  extract  it  by  making  traction 
downwards  and  backwards  in  the  axis 
of  the  pelvic  outlet.  Re-introduce 
the  finger  into  the  bladder  to  ascertain 
whether  there  may  not  be  another 
stone,  and  if  in  doubt  use  the  searcher. 
Inject  two  or  three  syringefuls  of  cold 
water  into  the  bladder :  dust  the 
wound  with  iodoform  ;  apply  no  dress- 
ings ;  tie  the  legs  together  if  the  pa- 
tient is  a  child,  and  send  him  back  to 
bed  as  quickly  as  possible.  If  there 
is  haemorrhage,  tie  any  bleeding  point 
which  is  seen,  or  if  the  blood  comes 
from  the  deep  part  of  the  wound,  in- 
troduce the  petticoated  tube  (Fig. 
336),  assuring  yourself  that  the  end  is 
in  the  bladder  by  injecting  water  and 
passing  a  probe  through  it.  Then  plug  firmly  round  with  strips 
of  lint  between  the  petticoat  and  the  tube. 

At  Guy's  Hospital  lateral  lithotomy  is  performed  on  a  straight 
staff,  by  the  operation  known  as  Key's,  A  good  description  of 
the  method  will  be  found  in  Bryant's  Surgery. 

The  si7-uctiires  divided  in  the  operation  are: — i,  the  skin;  2. 
the  superficial  and  deep  fascia ;  3,  a  few  branches  of  the  external 
haemorrhoidal  vessels  and  nerves ;  4,  the  transversus  perinei 
muscle,  vessels  and  nerve ;  5,  a  few  fibres  of  the  accelerator  urinae 
and  levator  ani  muscles ;  6,  the  compressor  urethrge  muscle ;  7, 
the  membraneous  portion  of  the  urethra ;  and  8,  the  prostate. 

The  dangers  of  the  operation  are  ; — A.  Before  the  point  of  the 


Petticoated  tube. 


694  DISEASES   OF   REGIONS. 

knife  has  entered  the  groove  in  the  staff — i,  wounding  the  rectum, 
either  from  cutting  too  perpendicularly,  or  from  not  having  had  it 
cleared  out  by  an  enema  ;  2,  wounding  the  artery  of  the  bulb  in 
consequence  of  beginning  the  incision  too  high,  or  directing  the 
point  of  the  knife  subsequently  too  much  upwards ;  and  3,  miss- 
ing the  groove  in  the  staff.  B.  On  entering  the  bladder — i,  let- 
ting the  point  of  the  knife  slip  out  of  the  groove  in  the  staff  and 
enter  the  cellular  tissue  between  the  bladder  and  rectum;  2,  cut- 
ting the  pudic  artery  from  holding  the  knife  too  much  lateralized  ; 
3,  sending  the  point  of  the  knife  through  the  posterior  wall  of  the 
bladder  ;  4,  cutting  the  prostate  too  widely,  and  dividing  its  cap- 
sule, whereby  the  urine  may  be  extravasated  into  the  cellular 
tissue  of  the  pelvis ;  5,  wounding  the  prostatic  plexus  of  veins ;  6, 
tearing  the  urethra  across,  and  so  pushing  the  bladder  off  the  end 
of  the  staff,  whilst  trying  to  pass  the  finger  into  the  bladder  (this 
accident  is  due  to  not  making  the  opening  into  the  urethra  large 
enough,  and  is  most  common  in  children  in  whom  the  tissues  are 
readily  lacerable)  ;  7,  making  too  small  an  incision  in  the  prostate 
so  that  the  parts  are  bruised  or  torn  in  removing  the  stone,  and 
inflammation  is  set  up  ;  8,  seizing  the  walls  of  the  bladder  by  the 
forceps.  These  dangers  may  he  best  avoided  by  obseiTing  the  fol- 
lowing rules — I,  feel  the  stone  with  the  staff  heioxe  you  begin  the 
operation;  2,  see  that  the  rectum  is  empty,  and  make  it  contract 
by  introducing  the  finger;  3,  make  the  external  incision  free  ;  4, 
feel  both  edges  of  the  groove  in  the  staff  with  the  finger,  and 
place  the  point  of  the  knife  betzveen  them  ;  5,  keep  the  point  of 
the  knife  well  pressed  into  the  groove  of  the  staff;  6,  take  care 
that  the  finger  is  pushed  into  the  bladder  in  contact  with  the 
naked  staff;  7,  do  not  remove  the  staff  till  the  finger  touches  the 
stone. 

The  difficulties  of  the  operation. — In  adults  the  chief  difficulty  is 
to  extract  the  stone  ;  in  children  to  get  into  the  bladder.  A.  The 
difficult)'  in  entering  the  bladder  depends  chiefly  on — i,  not  mak- 
ing the  opening  into  the  urethra  free  enough,  and  so  pushing  the 
finger  between  the  bladder  and  the  rectum  ;  2,  a  deep  perineum, 
so  that  the  finger  cannot  reach  the  bladder ;  in  such  case  a  blunt 
gorget  must  be  substituted  for  the  finger.  B.  The  difficulties  in 
extracting  the  stone  are — \,  the  stone  may  be  too  large  ;  2,  it  may 
get  behind  the  prostate  ;  3,  it  may  be  lodged  in  a  pouch  in  the 
upper  fundus  ;  4,  it  may  be  encysted ;  5,  it  may  break  or  crumble 
up;  6,  it  may  be  so  small  that  it  slips  from  between  the  blades  of 
the  forceps  ;  7,  there  may  be  an  enlargement  of,  or  tumor  in, 
the  prostate,  whereby  the  urethra  is  greatly  lengthened;  8,  there 
may  be  some  rickety  or  other  deformity  of  the  pelvic  bones. 
When  the  stone  is  behind  the  prostate,  curved  forceps,  with  the 


LATERAL    LITHOTOMY.  695 

blades  turned  down,  must  be  used  ;  when  the  stone  is  above  the 
pubes,  the  blades  must  be  turned  upwards,  the  handle  depressed, 
and  the  stone  pressed  down  by  the  hand  above  the  pubes.  When 
too  small  to  be  seized,  the  scoop  must  be  substituted  for  the  for- 
ceps. If  the  stone  breaks,  the  fragments  must  be  removed  by 
aid  of  the  scoop  and  syringe.  If  encysted,  it  may  be  scratched 
out  with  the  finger-nail,  or  freed  with  a  probe-pointed  bistoury. 
If  too  large  to  be  extracted,  the  wound  should  first  be  slightly  en- 
larged;  or,  this  being  insufficient,  three  expedients  remain— i,  to 
make  an  incision  in  the  opposite  side  of  the  prostate  ;  2,  to  crush 
the  stone ;  3,  to  do  the  suprapubic  operation.  The  first  of  these 
is  probably  the  best.  To  overcome  the  difficulty  of  an  enlarged 
prostate,  the  blunt  gorget  must  be  used  and  the  forceps  slid 
along  it.  A  fibrous  tumor  in  the  prostate  may  be  previously 
shelled  out.  Where  the  pelvic  outlet  is  too  small  to  allow  of  ex- 
traction, suprapubic  lithotomy  must  be  done. 

Causes  of  death  after  lithotomy. — i.  Diffuse  septic  inflamma- 
tion of  the  cellular  tissue  of  the  pelvis,  due  either  to  infiltration  of 
the  urine  from  too  free  cutting,  or  to  bruising  of  the  parts  in  ex- 
tracting a  large  stone  through  a  small  incision;  2,  peritonitis  due 
to  the  spread  of  the  inflammation  to  the  peritoneum,  or  to  a 
wound  of  the  back  of  the  bladder ;  3,  shock  from  too  prolonged 
an  operation;  4,  exhaustion  from  primary  or  secondary  haemor- 
rhage; 5,  blood-poisoning,  due  to  the  absorption  of  the  products 
of  putrefaction  (saprEemia),  or  to  septic  phlebitis  of  the  prostatic 
plexus  of  veins  and  pycemia ;  6,  cystitis;  and  7,  suppression  of 
urine.  The  state  of  the  kidney  is  of  the  most  serious  import. 
Where  these  are  healthy,  as  in  children,  lateral  lithotomy  is  one 
of  the  most  successful  operations  in  surgery ;  but  in  adults,  in 
whom  grave  kidney  mischief  often  exists,  it  is  liable  to  be  followed 
by  one  or  more  of  the  above  complications,  especially  diffuse 
pelvic  inflammation.  Thus,  in  boys,  when  death  occurs  it  is  gen- 
erally the  result  of  some  one  of  the  accidents  liable  to^  occur 
during  the  operation ;  in  adults  the  cause  is  usually  dependent 
primarily  on  kidney  mischief. 

The  after-treatment 'y~,  very  simple,  and  consists  in  little  more 
than  keeping  the  patient  clean,  and  in  regulating  the  secretions 
and  diet.  Adults  may  be  placed  on  a  mattress,  with  a  hole 
opposite  the  perineum,  for  the  purpose  of  letting  the  urine  drain 
through.  During  the  first  few  hours  it  is  essential  to  see  that  the 
wound  is  free.  Should  the  urine  not  escape  from  it,  it  is  prob- 
ably plugged  with  a  clot  of  blood ;  the  finger  must  then  be  passed 
into  the  wound,  or  if  a  tube  has  been  introduced,  this  must  be 
cleared  by  a  probe  or  feather,  or  by  syringing.  From  the  third 
to  the  fifth  day,  in  consequence  of  inflammatory  swelling,  more  or 


696  DISEASES   OF    REGIONS. 

less  of  the  urine  is  passed  by  the  urethra,  but  as  this  swelling  sub- 
sides, the  greater  part  may  again  pass  by  the  wound  ;  more,  how- 
ever, is  gradually  passed  by  the  natural  way  and  less  by  the 
wound,  as  the  latter  slowly  heals.  Should  secondary  haemorrhage 
occur,  the  wound  must  be  plugged  ;  or  if  this  fails  to  arrest  it, 
perchloride  of  iron  or  the  actual  cautery  must  be  used.  For  the 
treatment  of  the  other  complications  see  Cellulitis,  Peritonitis,  etc. 

jNIedian  LiTHOTOMV. — Pass  a  staff,  grooved  on  its  convexity, 
into  the  bladder,  and  with  the  left  forefinger  in  the  rectum,  feel 
for  the  apex  of  the  prostate.  Make  an  incision  with  a  straight 
bistoury,  with  its  back  towards  the  rectum,  in  the  median  line  of 
the  perineum,  beginning  about  half  an  inch  in  front  of  the  anus. 
Insert  the  point  of  the  knife  into  the  groove  of  the  staff  just  in 
front  of  the  prostate,  notching  the  apex,  and  cut  a  little  upwards, 
opening  the  membraneous  portion  of  the  urethra.  Withdraw  the 
knife,  slightly  enlarging  the  external  incision  upwards  if  necessary, 
and  pass  a  long  bulbous  probe  along  the  groove  of  the  staff  into 
the  bladder.  Withdraw  the  staff,  and  gently  work  the  forefinger 
into  the  bladder  along  the  probe,  thus  dilating  the  prostate.  Ex- 
tract the  stone  in  the  usual  way.  The  operation  is  suitable — i. 
For  small  stones  or  foreign  bodies ;  2.  When  it  is  important  that 
there  should  be  little  loss  of  blood  ;  3.  For  the  removal  of  new 
growths  ;  and  4.  For  exploring  the  bladder  in  doubtful  cases  of 
disease.  All  the  cutting  is  done  entirely  in  the  median  line  where 
no  vessels  exist ;  the  deeper  parts  of  the  wound  are  merely  dilated, 
not  cut.  Median  lithotomy  may  be  combined  with  lithotrity 
through  the  wound  (^perineal lithotrity),  a  straight  lithotrite  being 
then  used. 

Suprapubic  lithotomy  consists  in  opening  the  bladder  between 
the  pubes  and  the  peritoneal  fold.  It  is  the  method  that  should 
be  employed  for  the  removal  of  very  large  stones,  and  for  certain 
forms  of  tumor  in  the  bladder.  First,  pass  a  Petersen's  india- 
rubber  bag  into  the  rectum  and  dilate  it  with  water,  and  distend 
the  bladder  with  a  weak  antiseptic  solution,  it  will  then  rise  well 
into  the  abdomen  and  appear  as  a  prominent  tumor,  dull  to  per- 
cussion above  the  pubes.  Make  an  incision  in  the  middle  line 
immediately  above  the  symphysis  (Fig.  284,  b),  and  having  di- 
vided with  scissors  the  tissues  forming  the  linea  alba,  expose  the 
wall  of  the  bladder  by  gently  separating  the  fatty  tissue  that  lies 
in  front  of  it  with  the  finger  or  director,  avoiding  the  peritoneal 
fold,  and,  if  possible,  the  large  veins  which  ramify  in  this  situation. 
The  bladder  having  been  fixed  by  inserting  a  sharp  hook  into  its 
walls,  make  an  incision  into  it ;  introduce  the  finger  to  ascertain 
the  size  of  the  stone;  enlarge  the  wound,  if  necessary,  by  cutting 
towards  the  pubes,  and  extract  the  stone  with  the  finger  and 


INCONTINENCE   OF   URINE.  697 

Scoop,  or  with  the  forceps.  The  wound  in  the  bladder  may  be 
left  open,  and  the  patient  placed  on  his  side  to  ensure  an  efficient 
drain  and  prevent  the  tissues  being  infiltrated  with  urine  ;  or  it 
may,  if  the  bladder  and  urine  are  healthy,  be  closed  by  suture. 
Some  tie  in  a  full-sized  catheter,  but  it  is  not  necessary,  and  is 
perhaps  harmful. 

Calculus  in  the  female  bladder  is  much  less  common  than 
in  the  male,  a  fact  in  great  part  due  to  the  shorter  and  more 
dilatable  urethra  in  women,  to  the  absence  of  a  prostate  and  con- 
sequent exemption  of  the  female  from  chronic  retention  and 
phosphatic  deposits,  and  perhaps  also  to  the  more  regular  habits 
of  women.  The  symptoms  are  similar  to  those  in  the  male,  but 
are  sometimes  apt  to  be  accompanied  by  incontinence  of  urine. 
They  may  at  times  be  simulated  by  vascular  growths  in  the 
urethra,  by  uterine  disease,  and  by  hysteria. 

Treatment. — i.  When  the  stone  is  small,  rapid  dilatation  of  the 
urethra  with  the  three-bladed  dilator  or  dressing  forceps  is  the 
best  method  of  extraction.  2.  When  of  larger  size  (above  three- 
quarters  of  an  inch  in  children  and  one  inch  in  adults),  lithotrity 
with  removal  of  the  fragments  at  one  sitting  should  be  done.  3. 
When  too  large  for  removal  by  dilatation,  and  the  bladder  is  too 
contracted  to  allow  of  crushing,  the  suprapubic  operation  is  called 
for. 

Slow  dilatation,  dilatation  with  incision  {uTethral lithotoiu}') ,  and 
incision  through  the  vagina  {vaginal  lithotoiny)  are  very  liable  to 
be  followed  by  incontinence  of  urine,  especially  in  children. 

Incontinence  of  urine  or  enuresis. — Involuntary  escape  of 
urine  from  the  bladder  may  occur  under  several  conditions.  Thus 
—  I.  The  urine  may  dribble  away  as  fast  as  it  enters  the  bladder, 
in  consequence  of  paralysis  of  the  sphincter  vesicse  and  inability 
to  close  the  urinary  outlet  {true  incontinence).  2.  The  urine  may 
be  passed  involuntarily  during  sleep  without  any  organic  change 
in  the  urinary  apparatus  being  discoverable  {nocturnal  or  active 
incontinence) .  3.  The  urine  may  constantly  flow  away,  in  conse- 
quence of  the  bladder  being  over-distended  and  capable  of  hold- 
ing no  more  {retention  with  incontinence,  ox  false  incontinence). 
This  last  condition,  which  usually  depends  on  obstruction  to  the 
outflow,  will  be  described  under  Retention  of  Urine  (p.  723) .  The 
importance  of  recognizing  that  it  is  one  of  the  nature  of  retention 
rather  than  of  incontinence  cannot  be  too  strongly  insisted  upon. 
Whenever,  therefore,  a  patient  complains  that  he  is  unable  to  hold 
his  water,  or  that  it  is  continually  dribbling  away,  an  over-distended 
bladder  should  be  suspected,  the  abdomen  examined  for  such,  and 
a  catheter  passed. 

I.  True  incontinence  of  urine  is  very  rare.  ///  males,  it  may  be 
30 


698  DISEASES   OF   REGIONS. 

due — (a)  to  a  peculiar  form  of  enlargement  of  the  middle  lobe 
of  the  prostate  whereby  the  urethra  is  rendered  patent  instead  of 
being  obstructed  as  is  more  commonly  the  case  in  enlarged  pros- 
tate ;  {/>)  to  a  like  patency  of  the  urethra  from  the  impaction  of 
a  calculus  at  the  neck  of  the  bladder,  or  from  a  prostatic  calculus  ; 
(c-)  to  disease  or  injury  of  the  spinal  cord,  implicating  the  lumbar 
enlargement,  and  inducing  the  bladder  to  become  so  contracted 
and  thickened  that  it  cannot  hold  any  urine.  In  females,  it  may 
be  due — («')  to  over-dilatation  of  the  urethra,  as  in  extracting  a 
calculus  from  the  bladder;  {b)  to  the  injury  of  the  parts  during 
parturition;  and  {c)  to  vesico-vaginal  fistula.  The  treatment  coxi- 
sists  in  removing  the  cause,  or  if  this  is  impracticable,  in  render- 
ing the  padent's  condition  as  comfortable  as  possible  under  the 
circumstances  by  a  urinary  convenience. 

2.  Nociur7wl  or  active  incontinence  generally  occurs  in  children, 
and  must  be  distinguished  from  the  involuntary  passage  of  urine, 
which  is  an  occasional  symptom  of  thread-worms,  calculus,  long 
prepuce,  or  growth  in  the  bladder.  In  nocturnal  incontinence 
proper,  beyond  that  the  child  wets  his  bed,  no  sign  of  disease  of 
any  kind  is  discoverable.  Treatment. — Presupposing  that  the 
absence  of  thread-worms,  calculus,  long  prepuce  and  growth  in 
the  bladder  has  been  ascertained,  the  treatment  should  consist  in 
tonics,  cold  baths,  and  the  administration  of  belladonna  in  increas- 
ing doses  till  symptoms  of  belladonna  poisoning  appear.  The 
child  should  lie  on  his  side,  not  on  his  back,  and  be  awakened  at 
regular  intervals  to  pass  water.  I  have  found  the  continuous  gal- 
vanic current  of  service  ;  one  pole  should  be  applied  over  the 
urinary  centre  in  the  lumbar  region,  the  other  to  the  perineum. 
In  obstinate  cases.  Sir  Henry  Thompson  advises  the  application 
of  a  solution  of  silver  nitrate  (grs.  x  to  5J)  to  the  neck  of  the 
bladder. 

H/EMA'iUKiA,  or  bloody  urine,  is  generally  a  symptom  of  disease 
or  injury  of  the  urinary  organs,  but  may  also  occur  in  certain  con- 
stitutional conditions,  as  scurvy,  purpura,  malaria,  the  hsemor- 
rhagic  diathesis,  and  in  some  fevers.  When  blood  is  present  in 
large  quantities,  the  urine  will  be  bright  red  or  coffee  or  porter 
colored  ;  when  in  smaller  quantities,  of  various  shades  of  brown, 
to  which  the  term  "smoky"  is  applied.  Blood  maybe  simulated 
by  urates,  indican,  bile,  or  rhubarb  or  other  coloring  matter  which 
may  have  been  introduced  by  impostors.  The  dark  greenish  color 
of  the  urine,  which  is  produced  by  the  absorption  of  carbolic  acid 
from  a  wound,  must  not  be  mistaken  for  blood.  Blood  may  be 
distinguished  by  blood-globules  being  seen  under  the  microscope  ; 
by  the  spectroscope ;  or  by  the  ozonic  ether  test.  Add  a  few 
dro])s  of  tincture  of  guaiacum  to  the  suspected  urine,  and  then  an 


ACUTE   PROSTATITIS.  699 

excess  of  ozonic  ether ;  shake  the  mixture  and  allow  it  to  stand  ; 
it  will  assume  a  blue  color  if  blood  is  present.  The  same  reaction 
occurs  if  the  patient  is  taking  potassium  iodide.  Albumen  will 
be  detected  in  the  urine  if  blood  is  present  in  quantity. 

Source  of  the  blood. — The  blood  may  come  from — i,  the  kidney 
or  ureter;  2,  the  bladder  or  prostate ;  or  3,  the  urethra.  When 
from  the  kidney  or  in-eter  \t  may  be  due  to  {a)  injury,  {/>)  con- 
gestion or  inflammation,  {c)  Bright's  disease,  {d)  the  administra- 
tion of  turpentine,  or  the  application  of  a  cantharides  blister,  {e) 
the  presence  of  a  parasite,  the  Bilharzia  hgematobia,  in  the  pelvis 
of  the  kidney  in  persons  who  have  been  in  Africa,  (/)  the  impac- 
tion or  passage  of  a  calculus,  {g)  the  passing  of  a  catheter  up 
the  urethra,  or  (/z)  malignant  disease.  IVhen  from  the  bladder 
or  prostate  it  may  be  due  to  («)  injury,  (^)  calculus,  {c)  cystitis 
or  prostatitis,  or  {d)  villous  or  malignant  growths.  When  fro?n 
the  urethra  it  may  be  due  to  {a)  injury,  {b)  gonorrhoea  or  chan- 
cre, {c)  erectile  growths,  {d)  calculus,  (1?)  rupture  of  corpus 
spongiosum  in  chordee  or  sexual  intercourse. 

Diagnosis. — Blood  from  the  urethra  comes  before  the  urine,  is 
frequently  pure,  and  may  continue  flowing  between  the  acts  ot 
micturition.  From  the  bhidder  or  prostate,  it  generally  comes 
after  the  urine,  or  the  urine  contains  more  blood  at  the  end  than 
at  the  beginning  of  micturition  ;  it  is  often  clotted  from  remaining 
some  time  in  the  bladder,  and  the  urine  then  is  of  a  porter-like 
color.  From  the  kidney  it  comes  with  the  urine,  with  which  it  is 
intimately  mixed  {smoky  urine).  The  urine  may  then  contain 
blood-casts  of  the  renal  tubes,  or  when  it  comes  from  the  ureter, 
fibrinous  casts  of  the  ureter. 

The  treatment  resolves  itself  into  remedying  where  possible  the 
cause  (see  Diseases  of  Kidney,  Bladder,  etc.).  When  clots  have 
collected  in  the  bladder,  they  may  be  washed  out  with  a  stream 
of  warm  water  ;  but  when  they  are  decomposing,  it  may  be  neces- 
sary to  open  the  bladder  through  the  perineum  and  remove  them. 

DISEASES  OF  THE  PROSTATE. 

Acute  prostatitis. —  Causes. — Generally  gonorrhcea,  or  stric- 
ture of  the  urethra ;  less  frequently  cystitis,  impacted  calculus, 
and  passage  of  instruments.  Occasionally  in  gouty  subjects  it 
appears  to  occur  idiopathically.  Symptoms. — Micturition  is  fre- 
quent, and  attended  with  pain,  especially  at  the  end  of  the  act ; 
there  is  throbbing  and  continuous  pain  in  the  perineum  and  neck 
of  the  bladder,  and  pain  during  defgecation.  When  examined  by 
the  finger  in  the  rectum,  the  prostate  is  found  hot,  swollen,  and 
painful,  and  the  passage  of  a  catheter  causes  great  pain.     The 


700 


DISEASES   OF   REGIONS. 


febrile  disturbance  which  accompanies  it,  is  perhaps  ushered  in  by 
rigors.  Terminations. — Resolution,  abscess,  or  chronic  inflam- 
mation. Treatment. — Six  or  more  leeches  to  the  perineum;  hot 
hip-baths  ;  hot  poultices  to  the  perineum  ;  and  a  purgative  at  the 
onset,  followed  by  alkaline  medicines.  A  catheter  is  only  to  be 
passed  if  there  is  retention  of  urine. 

Abscess  of  the  prostate  is  generally  preceded  by  acute  in- 
flammation ;  but  chronic  abscess  may  be  produced  by  catheterism 
in  chronic  enlargement  of  the  organ.  Acute  abscess  may  be 
suspected,  when  in  the  course  of  acute  prostatitis  rigors  and  re- 
tention of  urine  supervene.  Fluctuation  can  at  times  be  felt 
through  the  rectum,  but  the  abscess  is  generally  first  discovered 
on  passing  a  catheter  for  the  relief  of  the  retention  of  urine,  when 
a  quantity  of  pus  escapes  from  the  urethra.  At  times  the  abscess 
may  burst  into  the  rectum  or  perineum.  Treatment. — Free  incis- 
ion in  the  middle  line  of  the  perineum  to  let  out  the  pus.  When 
the  pus  forms  around  the  prostate  instead  of  in  its  substance,  a 
periprostatic  abscess  is  said  to  have  occurred.  The  cause,  symp- 
toms, and  treatment  are  similar. 

Chronic  prostatitis  generally  occurs  as  a  sequel  to  the  acute. 
The  symptoms  are  similar,  but  of  much  less  intensity  ;  and  there  is 
a  glairy  discharge  with,  sometimes,  a  drop  or  two  of  blood  in  it. 
The  urine  is  cloudy  and  contains  pus  and  prostatic  casts.  Noctur- 
nal emissions  are  frequent.  If  the  in- 
flammation is  not  relieved,  cystitis  may 
follow,  and  the  bodily  and  mental  health 
become  seriously  impaired.  Treatment. 
— Blisters  to  the  perineum,  gentle  laxa- 
tives, tonics,  especially  iron,  change  of 
air  or  a  sea  voyage,  sea-bathing,  a  gene- 
rous diet,  and  the  avoidance  of  stimu- 
lants, horse-exercise  and  sexual  indulg- 
ence. The  application  of  silver  nitrate 
to  the  prostatic  urethra  is  recommended 
by  some  Surgeons  when  there  are  noctur- 
nal emissions. 

Hypertkophy,  or  chronic  enlargement 
of  the  prostate,  must  be  carefully  distin- 
guished from  the  enlargement  due  to  in- 
flammation. It  seldom  occurs  under  the 
age  of  fifty  or  sixty,  and  is  a  common, 
though  not  an  invariable,  disease  of  old 
men.  It  may  be  due  to  hyjjertrophy  ot  all  the  tissues  forming  the 
prostate  ;  or  the  glandular,  muscular,  or  fibrous  tissue  only  may 
be  affected,  then  often  forming  distinct  masses  in  the  substance  of 


Fig.  337. 


Enlargement  of  the  middle  lobe 
of  the  prostate.  (St.  Bartho- 
lomew's Hospital  Museum. J 


CHRONIC    PROSTATITIS.  70I 

the  organ.  The  enlargement  may  involve  the  whole  prostate,  or 
may  be  confined  to  one  or  other  of  the  lateral  lobes  or  to  the  so- 
called  middle  lobe  (Fig.  337).     The  cause  is  not  known. 

The  effects  of  chronic  enlargement  of  the  prostate  are  very  seri- 
ous when  the  outflow  of  urine  is  impeded,  similar  changes  occur- 
ring in  the  bladder,  ureters,  and  kidneys  as  described  under 
stricture.  The  bladder  behind  the  enlargement  forms  a  pouch  in 
which  some  urine  may  remain  after  each  act  of  micturition  unex- 
pelled,  and  there,  mixed  with  pus  and  mucus  from  the  walls  of  the 
inflamed  bladder,  undergo  decomposition,  probably  owing  to  the 
action  of  micro-organisms,  the  urea  being  converted  into  ammon- 
ium carbonate,  and  the  phosphate  in  consequence  precipitated. 

Symptovis. — Increased  frequency  of  micturition,  especially  at 
night ;  inability  to  propel  the  stream  to  the  same  distance  as  for- 
merly, owing  to  the  muscular  fibres  of  the  bladder  being  involved 
in  the  disease  ;  and  difficulty  in  commencing  the  act.  Later,  the 
bladder  is  imperfectly  emptied  ;  the  retained  urine  becomes  am- 
nioniacal  and  alkaline  in  reaction  ;  cystitis  is  set  up,  and  retention 
of  urine  may  finally  occur. 

Diagnosis. — These  symptoms  may  depend  upon  causes  other 
than  enlarged  prostate.  It  is  only  by  a  physical  examination  that 
the  nature  of  the  disease  can  be  accurately  made  out.  On  intro- 
ducing the  finger  into  the  rectum  the  prostate  is  felt  enlarged,  un- 
less the  middle  only  is  involved.  On  passing  a  catheter  no  ob- 
struction is  met  with  in  the  urethra ;  /.  e.,  the  catheter  passes  six 
or  seven  inches  without  meeting  with  any,  and  then  has  to  be 
well  depressed  before  it  can  be  made  to  enter  the  bladder.  Or 
an  ordinary  catheter  may  not  be  long  enough  to  enter  the  bladder, 
and  a  prostatic  catheter  may  have  to  be  used. 

Treatment. — In  the  early  stages,  so  long  as  the  bladder  can  be 
completely  emptied  by  the  patient's  own  efforts,  the  treatment 
should  be  directed  to  improving  the  general  health.  But  as  soon 
as  it  is  found  that  obstruction  is  beginning  to  come  on,  Harrison's 
olive-shaped  bougie  may  be  passed  daily  so  as  to  exert  pressure 

Fig.  338. 


Coiide  catheter. 

on  the  prostate,  and  dilate  the  canal.  If  it  is  found,  after  urine 
has  been  passed,  that  the  bladder  still  retains  some  ounces,  then 
catheterism  must  be  commenced.  A  soft  catheter,  or  when  the 
middle  lobe  is  enlarged,  a  coude  or  bi-coude  (Figs.  338,  339), 


702  DISEASES   OF   REGIONS. 

should  be  used  at  regular  intervals,  and  any  cystitis  which  may 
exist  should  be  treated  as  already  described.  As  the  disease  ad- 
vances the  passage  of  the  catheter  may  cause  a  very  irritable  con- 
dition of  the  bladder.  Under  such  circumstances  it  becomes  a 
question  whether  the  bladder  should  be  tapped  above  the  pubes, 

Fig.  339. 


•lESKEEEHaiEEasi 


Bi-coude  ciithctcr. 

and  a  cannula  kept  permanently  in  ;  or  whether  an  incision  in  the 
middle  line  of  the  pernineum  should  be  made  to  drain  the  blad- 
der. I  prefer  the  latter  method.  When  retention  occurs,  and  it 
cannot  be  reheved  by  a  catheter,  the  bladder  must  be  tapped 
above  the  pubes.  Recently  the  obstruction  has  been  overcome 
by  punching  out  a  piece  of  the  prostate  with  an  instrument  in- 
vented for  the  purpose,  by  boring  a  new  channel  with  the  galvano- 
cautery.  and  by  opening  the  bladder  above  the  pubes  and  remov- 
ing with  the  knife  or  cautery  the  obstructing  portion  of  the 
middle  lobe  {^prostatectomy^.  The  removal  of  the  obstructing 
middle  lobe  holds  out  the  best  prospect  of  success.  Castration 
is  recommended  as  likely  to  cause  shrinking  of  the  prostate,  in 
the  same  way  as  the  removal  of  the  ovaries  leads  to  atrophy  of 
fibroids  of  the  uterus. 

TuBtRCLE  OF  THE  PROSTATE  may  occur  in  the  course  of  general 
tuberculosis,  or  in  connection  with  tubercular  disease  of  the 
genito-urinary  tract.  It  gives  rise  to  inflammation,  and  sometimes 
suppuration,  in  or  about  the  organ  ;  but  its  diagnosis  will  depend 
'on  the  presence  of  tubercle  in  other  ])arts,  as  the  testicle,  bladder, 
vesiculai  seminales,  etc.  The  local  scraping  away  of  caseous 
material  may  give  some  temporary  relief. 

Malignant  disease. — Carcinoma  in  the  old,  and  sarcoma  in  the 
young,  may  occur  in  the  prostate,  but  both  are  rare.  Pain,  in- 
creased frequency  in  micturition,  with  passage  of  blood,  often 
pure,  at  the  end  of  the  act ;  the  presence  in  the  urine  of  shreds 
of  the  growth  ;  the  detection  in  the  rectum  of  a  swelling  of  the 
prostate  of  unequal  consistency  and  of  rapid  growth  ;  enlarge- 
Tnent  of  the  lumbar  and  often  also  of  the  inguinal  glands;  and 
wasting  and  cachexia,  are  the  symptoms  by  which  it  may  be 
known.  I'he  treatment  can  only  be  palliative  ;  /.  e.,  morphia  to 
subdue  pain,  nstrin;:;ents  to  check  hemorrhage,  and  catheterism 
or  supra-pubic  puncture  to  relieve  retention. 

Prosta'JIc  cai,culi  are  often  found  in  abundance  in  the  prostate 


GONORRHCEA.  703 

of  old  men,  in  the  form  of  small,  brown,  seed-like  bodies.  They 
are  composed  of  phosphates,  with  a  little  carbonate  of  lime  and 
a  large  proportion  of  animal  m.atter,  and  are  believed  to  be 
formed  by  the  inspissation  of  the  prostatic  secretion,  and  the 
subsequent  deposit  upon  it  of  the  earthy  salts.  Usually  they 
give  rise  to  no  syvipioms  but  occasionally  one  or  more  encroach 
upon  the  urethra,  and  may  attain  such  a  size  as  to  project  into 
the  bladder,  then  causing  painful  and  frequent  micturition,  invol- 
untary erections  and  escape  of  semen,  or  perhaps  retention  or 
incontinence  of  urine.  A  grating  sensation,  but  no  true  ring, 
may  be  elicited  on  the  passage  of  a  sound.  At  other  times  the 
calculi  may  escape  into  the  bladder  and  there,  collecting  in  con- 
siderable numbers,  give  rise  to  symptoms  of  stone.  Moreover, 
one  or  more  may  be  periodically  passed  by  the  urethra.  T^reat- 
nient. — Unless  the  symptoms  are  severe,  the  calculi  are  better  left 
alone ;  but  should  they  attain  a  large  size,  or  give  rise  to  reten- 
tion, etc.,  they  should  be  removed  through  a  median  incision  in 
the  perineum.  Extraction  by  the  urethral  forceps  is  not  likely  to 
succeed ;  but  there  is  no  harm  in  trying,  if  all  gentleness  is  used. 
Where  they  have  collected  in  the  bladder  they  may  be  washed 
out  by  Bigelow's  evacuator. 

DISEASES    OF    THE    URETHRA. 

Simple  urethritis,  or  inflammation  of  the  urethra  of  a  non- 
specific character,  may  be  due  to  injury,  catheterism,  gout,  the 
irritation  of  worms,  the  abuse  of  alcohol,  or  contact  with  leucor- 
rhceal  discharges.  Signs. — Simple  inflammation  of  the  urethra  is 
attended  by  a  catarrhal,  and  at  times  by  a  muco-purulent  dis- 
charge, and  except  in  the  mildest  forms,  it  cannot  always,  without 
taking  into  account  the  history  of  the  case,  be  distinguished  from 
gonorrhoea.  Like  the  latter  affection  it  may,  though  much  more 
rarely,  be  complicated  by  cystitis,  prostatitis,  epididymitis,  neph- 
ritis, synovitis,  and  ophthalmia.  The  treatment  is  similar  to  that 
for  gonorrhoea. 

GoNORRHCEA  is  an  acute,  infective,  and  specific  inflammation, 
attended  with  a  muco-purulent  discharge.  In  the  male  it  is  most 
common  in  the  urethra,  in  the  female  in  the  vagina  and  about 
the  vulva ;  but  it  may  attack  any  mucous  membrane  exposed  to 
contagion. 

Cause. — In  the  male  it  is  nearly  always  due  to  direct  contagion, 
and  in  the  female  it  is  also  commonly  contracted  in  this  way  ;  but 
in  the  female  it  may  possibly  be  developed  dc  novo,  i.  <?.,  evolved 
from  a  non-pathogenic  organism  through  want  of  cleanliness  and 
the  decomposition  of  retained  and  foul  discharges. 


704 


DISEASES   OF    REGIONS. 


Fig.  340. 


1000.      (After     Stern- 


Pathology. — Gonorrhoea  is  now  regarded  as  a  specific  and  in- 
fective inflammation,  in  that  it  has  a  distinct  incubative  period, 
is  highly  contagious,  extends  along  the  mucous  tracks  it  attacks, 
and  may  secondarily  affect  the  fibrous  tissues  of  the  body  gen- 
erally, as  in  gonorrhceal  rheumatism  and  sclerotitis,  and  in  that 
the  micro-organism.  Fig.  340  {goiiococcus),  found  in  the  dis- 
charges after  gelatine  cultivations  to 
four  generations,  will  set  up  a  sim- 
ilar inflammation  in  any  mucous 
membrane  to  which  it  is  applied. 
In  the  male,  gonorrhoea  usually  be- 
gins in  the  mucous  membrane  of 
the  fossa  navicularis,  and  if  allowed 
to  run  its  course,  extends  backwards 
along  the  urethra,  and  thence  may 
spread  to  the  vesiculae  seminales, 
prostate,  bladder,  and  testicle.  In 
the  female  it  usually  begins  about 
the  vulva,  whence  it  may  extend  to 
the  vagina,  and  more  rarely  to  the 
urethra,  bladder,  uterus  and  Fal-' 
lopian  tubes. 
Svmptoms. — Gonorrhoea  is  generally  divided  into  three  stages. 
In  \\\t  first  staii^c,  usually  lasting  from  a  few  days  to  a  week,  there 
is  some  itching  about  the  external  meatus  followed  by  a  yellowish- 
white  discharge.  In  the  second  or  acute  stage,  there  is  great  pain 
on  urination,  a  thick  yellowish-green  discharge,  and  redness  and 
swelling  about  the  lips  of  the  meatus.  In  the  third  or  chronic 
stage,  which,  when  prolonged,  is  known  as  gleet,  the  discharge 
becomes  thin  and  watery,  and  there  is  no  longer  pain  on  urina- 
tion. 

The  treatment  varies  according  to  the  stage  of  the  disease. 
Generally  it  may  be  said  that  at  the  onset  a  smart  purge  should 
be  given,  and  the  bowels  subsequently  kept  slightly  relaxed  by 
saline  aperients  ;  whilst,  throughout  its  course,  stimulants  of  all 
kinds  must  be  withheld,  demulcent  drinks  freely  taken  to  dilute 
the  urine,  the  parts  ke|)t  scrupulously  clean,  the  testicles  sup- 
ported in  a  suspensory  bandage,  and  active  exercise  and  exposure 
to  cold  and  wet  avoided.  In  ihe  first  stage  the  so-called  abortive 
treatment  is  often  successful.  It  consists  in  the  use  of  astringent 
injections,  and  the  internal  administration  of  such  drugs  as 
copaiva,  cubebs,  or  sandal  oil.  An  excellent  plan  is  that  sug- 
gested by  Mr.  Gheyne  of  passing  a  bougie  composed  of  iodoform, 
oil  of  eucalyptus,  and  oil  of  theobroma,  into  the  urethra  after  the 
patient  has  passed  water,  and  allowing  it  to  dissolve  there,  and 


CHORDEE.  705 

subsequently  injecting  freely  with  a  lotion  of  sulpho-carbolate  of 
zinc.  The  bougie  should  be  repeated  if  necessary.  In  this  way 
the  disease  may  often  be  cured  in  a  few  days.  In  the  second 
stage  most  Surgeons  recommend  a  soothing  plan  of  treatment, 
merely  keeping  the  bowels  relaxed,  and  giving  such  medicines  as 
hyoscyamus,  bicarbonate  of  potash,  etc.  Unless,  however,  the 
inflammation  is  very  intense,  injections  of  sulphocarbolate  or 
sulphate  of  zinc,  or  of  tannic  acid,  may  be  safely  used,  and  will 
greatly  lessen  the  duration  of  the  disease.  In  the  third  stage, 
astringent  injections,  combined  with  the  internal  use  of  copaiva, 
cubebs,  or  sandal  oil,  are  indicated.  This  stage  is  often  very 
difficult  to  cure,  and  where  one  remedy  or  injection  fails,  another 
must  be  tried.  The  passage  of  a  full-sized  bougie  is  at  times  of 
much  service.  Spring  bougies  coated  with  thallin  have  been 
lately  highly  recommended. 

Complications  of  Gonorrhcea. — Complications  of  some  kind 
frequently  occur  during  an  acute  attack  of  gonorrhoea.  They  may 
be  conveniently  classified  according  as  they  depend  upon  : — A.  The 
local  inflammation  of  the  urethra — i,  balanitis  ;  2,  chordee  ;  3, 
phimosis  ;  4,  paraphimosis  ;  5,  lacunar  and  perineal  abscess  ;  6, 
retention  of  urine ;  7,  warts ;  8,  stricture ;  9,  induration  of  the 
penis  (rare).  B.  The  extension  of  the  inflammation  along  the 
genito-iirinary  mucous  membrane — i,  prostatitis;  2,  cystitis;  3, 
Cowperitis ;  4,  vesiculitis;  5,  epididymitis;  6,  pyelitis  and 
nephritis  (very  rare)  ;  and  in  the  female  :  7,  metritis;  8,  salpin- 
gitis ;  9,  pelvic  peritonitis  and  cellulitis.  C.  The  extension  of  the 
inflammation  to  the  lymphatics  of  the  urethra — i,  lymphangitis  ; 

2,  bubo  ;  and  3,  blood-poisoning.    D.  The  local  inoculation  of  dis- 
tant 7nucous  membranes  itntli  the  discharge — i,  gonorrhceal  con- 
junctivitis ;   2,  nasal  catarrh  ;  and  3,  catarrhal  inflammation  of  the 
rectum.     E.   The  absorption  by  the  blood-vessels  of  the  septic  pro-- 
ducts — I,  gonorrhceal  rheumatism  ;  2,  gonorrhceal  sclerotitis  ;  and, 

3,  septicaemia  and  pyaemia.  Of  these  complications,  some  are 
exceedingly  rare,  whilst  others,  as  balanitis,  chordee,  phimosis, 
pai-aphimosis,  epididymitis,  bubo,  and  stricture  are  common.  Most 
of  these  complications  are  described  under  diseases  of  the  various 
organs  in  other  parts  of  the  book.  Here  a  short  account  of  the 
following  only  will  be  given. 

Balanitis,  or  inflammation  of  the  glans  penis,  often  occurs  in 
gonorrhoea.  The  glans  is  red  and  swollen,  of  a  bright,  red  colour 
and  often  excoriated.  Cleanliness  and  astringent  lotions  are  all 
that  is  necessary. 

Chordee,  or  painful  erection  of  the  penis,  is  very  common  in 
gonorrhoea.  The  erected  penis  has  often  a  downward  curve,  which 
is  generally  believed  to  depend  on  the  inflammatory  products  in 


7o6  DISEASES   OF   REGIONS.    . 

and  around  the  urethra  preventing  the  corpus  spongiosum  from 
becoming  distended  equally  with  the  corpora  cavernosa.  Some, 
however,  attribute  the  chordee  to  spasm  of  the  urethral  muscles. 
It  occurs  chiefly  at  night-time  when  the  patient  is  warm  in  bed, 
and  greatly  disturbs  his  rest.  The  treattyiejit  consists  in  the  ad- 
ministration of  such  sedatives  as  potassium  bromide  or  of  cam- 
phor and  opium  in  the  form  of  a  pill  or  suppository,  and  the 
local  application  of  cold,  or  a  hot  bath  before  going  to  bed. 

CowPERiiis,  or  inflammation  of  Cowper's  glands,  sometimes 
occurs,  and  then  usually  late  in  the  second  stage  of  gonorrhoea.  It 
may  be  known  by  the  formation  of  a  painful  swelling  on  one  or 
both  sides  of  the  middle  line  of  the  perineum.  The  swelling,  at 
first  hard,  subsequently  becomes  soft  and  fluctuating  as  pus  forms. 
It  may  be  distinguished  from  ordinary  perineal  abscess  by  its  one- 
sided position,  lyeatmeui.  —  Warmth  to  the  perineum,  and 
when  suppuration  had  occurred,  a  free  incision. 

Lymphangitis  and  bubo. — The  inflamed  lymphatic  vessels 
appear  as  red  streaks  running  along  the  dorsum  of  the  penis  to  the 
inguinal  glands,  the  penis  itself,  especially  the  glans,  being 
swollen,  turgid,  and  dusky  red  in  color.  It  may  terminate  in 
suppuration  of  the  inguinal  glands,  or  even  in  blood-poisoning. 
In  the  ordinary  gonorrhceal  bubo,  inflamed  lymphatics  are  not  as 
a  rule  visible  on  the  penis,  and  the  inflammation  which  may 
occur  both  in  and  around  the  glands  generally  terminates  without 
suppuration.  Treatment. — Rest,  and  attention  to  the  bowels,  is 
all  that  is  usually  required.  If,  however,  suppuration  threatens, 
hot  linseed  poultices  and  fomentations  must  be  applied,  and  a 
free  incision  in  a  vertical  direction  made  as  soon  as  pus  forms. 
Should  a  sinus  remain  after  the  bubo  has  been  opened  or  burst 
spontaneously,  it  should  be  laid  freely  open,  scraped,  and  stuffed 
with  aseptic  gauze,  that  it  may  heal  from  the  bottom. 

Stricture  of  the   Urethra. 

True,  or  organic  s'iricture  of  the  ure'jhra  is  a  cicatricial 
narrowing  of  the  canal  at  one  or  more  spots,  due  to  disease,  in- 
jury, or  congenital  defect.  A  temporary  narrowing  of  the  urethra 
may  also  occur  from  spasm  of  the  muscular  tissue  surrounding  it, 
or  from  congestion  of  its  lining  membrane,  conditions  to  which 
the  terms  spasinodic  and  coiv^estive  stricture  are  sometimes  ap- 
plied. Such,  however,  seldom  occur  without  the  co-existence  of 
organic  stricture.  Obstruction  of  the  urethra  by  a  calculus,  an 
enlarged  prostate,  or  by  pressure  from  without,  as  from  an  abscess 
or  fractured  pelvic  bone,  should  not  be  spoken  of  as  stricture. 

Cause  and  formation  of  stricture. — A  stricture  is  generally  the 


STRICTURE    OF    THE    URETHRA.  707 

result  of  chronic  inflammation,  such  as  neglected  gonorrhoea  or 
gleet,  or  more  rarely,  a  simple  urethritis  in  a  gouty  subject.  In 
such  cases  the  mucous  and  sub-mucous  tissue  become  infiltrated 
with  inflammatory  products,  which  are  ultimately  organized  into 
fibrous  tissue  ;  and  this  again  slowly  contracts,  narrowing  the 
canal.  More  rarely  a  stricture  may  be  caused  by  the  contraction 
of  ;i  cicatrix  following  laceration  or  rupture  of  the  urethra,  pro- 
duced by  injury  inflicted  either  from  within  by  the  careless  pass- 
age of  instruments  or  the  use  of  too  strong  injections,  or  from 
without  by  kicks,  falls,  etc.,  on  the  perineum.  Occasionally  it 
may  be  due  to  the  contraction  of  the  cicatrix  following  a  urethral 
chancre.  In  some,  instances  no  cause  can  be  ascribed.  A  few 
cases  are  congenital. 

Varieties. — Organic  strictures  have  been  divided  ( i )  according 
to  their  cause,  into  idiopathic  and  tratimatic ;  (2)  according  to 
their  anatomical  appearances,  into  liueai',  annular,  i^-regidar  or 
tortuous,  bridle  or  pack-thread,  and  tunnelled,  terms  which  suffi- 
ciently explain  themselves;  (3)  according  to  whether  an  instru- 
ment can  or  cannot  be  passed,  into  permeable  and  impermeable ; 
(4)  according  to  their  behavior,  into  simple,  sensitive  or  irrita- 
ble, and  contractile  or  recurring ;  and  (5)  according  to  their 
structure,  mto  fibrous,  elastic,  and  cartilaginous. 

Situation. — Stricture  may  occur  in  any  part  of  the  urethra  save 
the  prostatic.  It  is  generally  said  to  be  most  common  in  the 
bulbous  part  of  the  spongy  portion,  but  Otis  and  others  main- 
tain that  it  is  most  often  found  in  the  anterior  part  of  the  urethra, 
and  that  what  have  been  considered  deep  strictures  are  only 
spasmodic  conditions  consequent  upon  the  reflex  irritation  of  the 
true  stricture  in  front.  In  the  penile  portion  of  the  urethra 
strictures  are  usually  multiple. 

Results. — When  a  stricture,  or  indeed  any  mechanical  obstruc- 
tion to  the  free  flow  of  urine  from  the  bladder,  such  as  a  long 
prepuce,  an  enlarged  prostate,  a  narrow  meatus,  etc.,  has  existed 
some  time,  serious  structural  changes  (Fig.  341)  occur  in  the 
urinary  apparatus  on  the  proximal  side  of  the  lesion,  i.  e..  in  i, 
the  urethra  behind  the  stricture  ;  2,  the  bladder ;  3,  the  ureters  ; 
and  4,  the  kidneys.     Thus  : 

I.- The  urethra  behind  the  stricture  becomes  dilated,  and  ul- 
ceration may  occur  leading  to  perforation,  urinary  abscess  and 
fistula ;  or  rupture  may  take  place  suddenly  during  straining,  and 
be  followed  by  extravasation  of  urine. 

2.  The  bladder,  in  consequence  of  its  efforts  to  expel  the  urine, 
becomes  thickened  from  hypertrophy  of  its  muscular  coat.  The 
mucous  membrane  may  become  inflamed  and  thickened  ;  or  owing 
to  the  pressure  of  the  urine  may  be  protruded  through  the  mus- 


7o8 


DISEASES   OF   REGIONS. 


EiG.  341. 


cular  fasciculi,  forming  sacculi,  in  wliich  stale  urine  may  collect 
or  a  calculus  form. 

3.  The  ureters  become  dilated,  their  muscular  coats  hyper- 
trophied,  and  their  lining  membrane  sometimes  inflamed. 

4.  The  kidneys  become  disorganized,  in  part  from  the  backward 
pressure  of  the  retained  urine  and  in  part  from  the  spread  of 
inflammation  from  the  bladder  up  the  ureter  to  the  pelvis.  See 
Diseases  of  Kidneys,  p.  667. 

Symptoms. — A  gleety  discharge,  increased  frequency  of  mictur- 
ition, and  perhaps  some  pain  in  the 
act,  twisting  or  forking  of  the  stream, 
or  the  escape  of  a  few  drops  of  urine 
after  the  stream  has  ceased,  are  early 
signs  of  stricture.  Then  the  stream 
gets  gradually  smaller,  and  is  passed 
with  increasing  difficulty  and  strain- 
ing, till  finally  the  urine  may  only  be 
voided  drop  by  drop,  or  complete 
retention  may  set  in.  In  some  in- 
stances an  attack  of  retention  is  the 
first  sign  of  the  disease.  In  ne- 
glected cases  the  straining  may  pro- 
duce piles  or  prolapse  of  the  rectum  ; 
or  cystitis  may  be  set  up  and  the 
urine  become  ammoniacal  and  turbid 
from  the  presence  of  pus  and 
mucus  ;  or  the  bladder  may  become 
over-distended,  and  the  urine  dribble 
involuntarily  away.  This  condition 
of  overflow  should  be  carefully  dis- 
tinguished from  incontinence  (see  p. 
697).  At  first  there  are  usually  no 
constitutional  symptoms  ;  but  as  the 
obstruction  begins  to  tell  on  the 
bladder  and  kidneys,  dyspeptic 
tro>ibles  are  developed  ;  the  patient  loses  weight,  his  countenance 
becomes  anxious,  he  suffers  from  chilliness  and  occasional  rigors, 
from  pain  in  the  loins,  and  later,  from  feverish  attacks  and  un- 
mistakable signs  of  kidney  mischief.  Thus  a  stricture  which  in 
itself,  if  kept  properly  dilated,  is  not  a  serious  disease,  becomes  so 
when  neglected,  and  chronic  bladder  and  kidney  trouble  are  al- 
lowed to  be  set  up.  It  may  then  end  fatally  from  an  intercurrent 
attack  of  acute  cystitis  or  nephritis,  or  from  extravasation  ot 
urine  and  its  consequences  occurring  during  an  attack  of  reten- 
tion. 


The  effects  of  obstruction  to  the  out- 
flow of  urine  from  the  bladder  on 
the  urinary  apparatus. 


STRICTURE    OF   THE   URETHRA.  709 

A  diagnosis  can  only  be  made  with  certainty  by  examining  the 
urethra  with  instruments.  First  take  a  No.  8  or  9  black  bougie 
or  catheter,  and  if  this  passes  easily  try  successively  larger  sizes  till 
the  obstruction  is  met  with.  If,  on  the  other  hand,  it  will  not 
pass,  try  a  smaller  bougie  till  one  is  found  that  will  go  into  the 
bladder.  If  the  obstruction  to  the  passage  of  the  bougie  is  met 
with  within  six  inches  of  the  meatus,  a  stricture  exists ;  but  if  it  is 
further  than  this  the  case  is  one  of  enlarged  prostate.  Do  not 
mistake  the  catching  of  the  end  of  the  bougie  in  the  lacuna  or  at 
the  triangular  Hgament,  or  the  spasm  that  may  be  present  on  the 
first  trial,  for  a  stricture.  Having  discovered  the  stricture,  meas- 
ure the  distance  from  the  meatus  on  the  catheter  or  bougie.  Next 
pass  a  bulbous  stem  (Fig.  342)   through  the  stricture,  and  then 

Fig.  342. 


Bulbous  stem. 

withdraw  it,  noting  on  the  stem  where  the  bulb  is  caught  in  the 
act  of  withdrawal.  This,  when  compared  with  the  distance  noted 
on  the  catheter,  will  indicate  the  length  of  the  stricture.  In  the 
same  way  the  existence  of  other  strictures  can  be  discovered. 
The  calibre  of  the  stricture  may  be  measured  by  Otis'  urethro- 
meter  (Fig.  343). 

The  method  of  passing  a  bougie  or  catheter  can  be  much  better 

Fig.  343. 


~"*^^^ 


Otis'  urethrometer. 


learnt  by  five  minutes'  practice  than  by  any  written  instructions. 
Here  only  the  general  rules  for  passing  such  will  be  given,  i. 
Carefully  examine  the  instrument  to  see  that  it  is  quite  clean, 
perfectly  smooth,  not  defective  in  any  part,  and,  in  the  case  of  a 
catheter,  that  it  is  pervious,  in  order  to  avoid  respectively  the 
dangers  of  septic  infection,  laceration  of  the  urethral  mucous  mem- 
brane, the  breaking  off  of  the  end  of  the  catheter  in  the  stricture, 
and  the  annoyance  of  finding  that  when  the  catheter  has  been 
passed  it  is  choked  and  urine  will  not  flow  through  it.  2.  Warm 
and   oil   the  instrument;  a  cold   catheter  is  unpleasant   to   the 


yiO  DISEASES   OF   REGIONS. 

patient,  and  tends  to  produce  spasm  ;  an  unoiled  catheter  does  not 
glide  easily  along  the  urethra.  3.  Place  the  patient  in  the  recum- 
bent position  if  instrumentation  is  to  be  practised  for  the  first 
time,  lest  faintness  be  produced.  In  old-standing  cases,  where 
the  urethra  is  callous,  the  patient  may  stand  with  his  back  against 
a  wall.  4.  Pass  the  instrument  with  the  greatest  gentleness  and 
use  no  force. 

The  difficulties  that  may  be  met  with  in  passing  an  instrument 
are:  i.  The  point  may  catch  in  a  lacuna  or  fold  of  mucous  mem- 
brane. This  is  best  avoided  by  keeping  the  point  at  first  on  the 
floor  of  the  urethra.  2.  It  may  hitch  where  the  urethra  passes 
through  the  triangular  ligament.  Should  it  do  so,  withdraw  it  a 
little,  and  direct  the  point  against  the  roof  of  the  urethra.  3.  It 
may  enter  a  false  passage.  This  may  be  known  to  have  occurred 
(«•)  by  the  handle  being  deflected  from  the  middle  line,  (/^)  by 
the  catheter  being  felt  to  be  out  of  the  right  passage  by  the  finger 
in  the  rectum,  {c)  by  free  bleeding  if  the  false  passage  is  recent, 
(c/)  by  no  urine  escaping,  (,?)  by  the  point  not  moving  freely  as 
it  does  when  in  the  bladder.  The  formation  of  a  false  passage 
may  be  prevented  by  using  no  force  ;  and  entering  an  old  one 
may  be  avoided  by  using  a  silver  catheter  and  directing  its  point 
along  the  wall  of  the  urethra  opposite  to  that  in  which  the  open- 
ing into  the  false  passage  is  situated. 

The  local  and  constitutional  effects  that  occasionally  follow  the 
introduction  of  instruments. — Among  the  local  effects  may  be 
mentioned — i,  haemorrhage;  2,  false  passage;  3,  abscess;  4,  ex- 
travasation of  urine,  and  5,  inflammation  of  the  prostate,  testicle, 
or  bladder.  Among  the  constitutional  effects — i,  syncope;  2, 
rigors  ;  3,  urethral  fever;  4,  suppression  of  urine  ;  and  5,  pyaemia. 
Local  effects — i.  Haemorrhage  may  be  due  to  laceration  of  the 
mucous  membrane  of  the  urethra  by  the  careless  passage  of  the 
instrument,  or  to  congestion  of  the  urethra  in  the  neighborhood 
of  the  stricture ;  in  either  of  these  cases  the  blood  may  flow  on 
the  removal  of  the  catheter,  the  point  of  which,  moreover,  will  be 
blood-stained.  Haemorrhage,  however,  may  come  from  the 
kidney,  consecjiient  u])on  reflex  congestion  due  to  the  irritation  of 
the  neck  of  the  bladder  by  the  catheter.  The  blood  will  then 
only  appear  in  the  urine  after  some  time  has  elapsed  (see  Hema- 
turia, p.  698).  2.  A  false  passage  may  be  produced  by  using 
too  much  force,  or  by  applying  force  in  the  wrong  direction.  It 
is  known  to  have  been  made  by  the  catheter  being  felt  to  slip 
suddenly  onwards,  by  the  handle  deviating  from  the  middle  line, 
by  the  point  being  felt  out  of  the  urethra  by  the  finger  in  the 
rectum,  and  by  the  ])atient  complaining  of  severe  ])ain.  The 
catheter  should  be  at  once  withdrawn  and  not  passed  again  for  a 


STRICTURE   OF   THE   URETHRA.  7I1 

week  or  more,  to  allow  the  wound  to  heal.  3.  Abscess  ;  4,  extra- 
vasation of  urine  ;  and  5,  inflammation  of  the  prostate,  testicle, 
and  bladder,  require  no  comment  here.  General  effects — i. 
Syncope  occasionally  occurs  on  the  first  passage  of  a  catheter. 
It  is  best  avoided  by  passing  the  instrument  with  the  patient  in 
the  recumbent  posture.  2.  The  rigors  which  sometimes  follow 
the  first  introduction  of  an  instrument  appear  to  depend  upon 
some  nervous  shock,  and  may  occur  where  all  gentleness  has  been 
employed  and  no  local  injury  whatever  has  been  inflicted.  3. 
Urethral  fever  is  most  frequent  in  old  people,  and  may  supervene 
within  a  day  or  two  of  the  first  catheterization.  It  begins  with 
rigors  followed  by  high  fever,  and  usually  terminates  in  a  few 
days  with  profuse  sweating.  Occasionally,  however,  it  may  end 
fatally,  in  which  case  there  is  nearly  always  some  chronic  kidney 
disease  discovered  at  the  autopsy.  Sir  Andrew  Clark  has  called 
attention  to  the  possible  occurrence  of  death  after  the  passage  of 
an  instrument  in  old  men  without  any  kidney  or  bladder  trouble 
to  account  for  it.  4.  Where  suppression  of  urine  has  been  ob- 
served there  has  always  been  some  pre-existing  kidney  mischief. 
5.  Pyaemia  is  rare,  but  has  occasionally  been  noted. 

The  treatment  of  organic  stricture  resolves  itself  into  restoring 
the  patency  of  the  urethra  by  causing  the  absorption  and  destruc- 
tion of  the  inflammatory  or  cicatricial  material  producing  the 
obstruction,  and  subsequently  preventing  recontraction.  The 
methods  employed  for  restoring  the  patency  of  the  urethra  are  : 
I.  Slow  dilatation.  2.  Rapid  dilatation.  3.  Forcible  dilatatio7i  or 
splitting.  4.  Division  of  the  stricture  from  witliifi  (internal 
urethrotomy).  5.  Division  of  the  stricture  from  ivithout  (external 
urethrotomy).  6.  Destruction  of  the  stricture  by  caustics.  7. 
Electrolysis.  Treatment  by  caustics  may  be  said  to  have  now  be- 
come obsolete,  and  will  not  be  further  referred  to.  Of  the  other 
methods  slow  dilation  is  no  doubt  the  simplest  and  safest,  and  is 
the  one  that  in  the  large  majority  of  cases  should  be  used. 
Where,  however,  time  is  an  object  or  the  stricture  cannot  be  di- 
lated by  the  slow  method  beyond  the  size  of  a  No.  4  or  5  catheter, 
or  severe  constitutional  or  local  symptoms  are  set  up  on  each  oc- 
casion that  a  catheter  is  passed,  rapid  dilatation  may  be  tried. 
Where  again  the  continual  presence  of  a  catheter  in  the  urethra 
cannot  be  borne  on  account  of  the  local  irritation  which  it  causes, 
or  the  stricture  is  resilient  and  rapidly  recontracts  after  it  has 
been  fully  dilated,  internal  urethrotomy  or  electrolysis  may  be 
practiced,  especially  if  the  stricture  is  in  the  penile  portion  of  the 
urethra.  Further,  when  the  stricture  is  of  cartilaginous  con- 
sistency, and  wfll  not  yield  to  dilatation,  or  the  perineum,  in  addi- 
tion, is  riddled  with  sinuses,  external  urethrotomy  by  Syme's  or 


712  DISEASES   OF   REGIONS. 

Wheelhouse's  method  may  be  performed.  Lastly,  when,  after 
persistent  attempts,  it  is  found  that  an  instrument  cannot  be 
passed  through  the  stricture,  electrolysis  may  be  attempted,  or 
external  urethrotomy  by  Wheelhouse's  method  may  be  under- 
taken. \\'hen  the  symptoms  are  urgent,  as  from  retention  or 
extravasation  of  urine,  other  measures  may  be  required.  See 
Retention  and  Extravasation  of  Urine  (pp.  721  and  723).  For- 
cible dilatation  or  splitting  does  not  commend  itself  to  my  judg- 
ment, and  should  not  in  my  opinion  be  employed. 

If  a  catheter  will  not  pass  on  the  first  attempt  it  must  not  at 
once  be  assumed  that  the  stricture  is  impervious,  as  it  may  yield 
on  a  future  occasion ;  but  gentle  and  persevering  attempts  with 
fine  catgut  bougies,  filiform  bougies,  French  silk  bougies,  or 
whalebone  bougies,  should  be  made.  The  patient,  presupposing 
there  is  no  retention,  may  be  asked  to  pass  water,  and  whilst  the 
urine  is  flowing,  and  the  stricture  is  in  consequence  dilated  by  the 
stream,  a  bougie  one  or  two  sizes  smaller  than  the  stream  may 
sometimes  be  slipped  in.  If  the  point  of  a  catheter  is  firmly 
grasped,  indicating  that  it  is  in  the  mouth  of  the  stricture,  gentle 
pressure  may  then  be  used  to  push  it  onwards.  If  in  any  of  these 
ways  a  fine  bougie  can  be  got  in,  it  should  not  be  removed  till  the 
patient  is  compelled  to  pass  water,  when  a  small  catheter  may  be 
subsequently  substituted  for  it,  or  a  railway  catheter  slid  over  the 
bougie  before  the  latter  is  removed.  If  after  persevering  at- 
tempts, even  with  the  patient  under  the  influence  of  chloroform, 
success  is  not  attained,  the  patient  should  be  prepared  for  a 
further  trial  by  rest  in  bed  for  a  week  or  so,  daily  hot  baths, 
purgatives,  and  the  administration  of  opium.  When  other  means 
have  failed,  before  resorting  to  a  cutting  operation,  electrolysis 
under  some  circumstances  may  be  tried. 

Slow  or  iniermittent  dilatation  is  the  simplest  and  safest 
method  of  treatment,  and  does  not  usually  necessitate  the  patient 
leaving  his  ordinary  employment.  The  various  catheters  and 
bougies  employed  are  so  well  known  as  hardly  to  reciuire  descrip- 
tion here.  All  that  need  be  said  is  that  the  soft,  flexible,  black 
French  bougie,  with  a  bulbous  end,  is  now  as  a  rule  generally 
preferred  to  a  metal  or  gum-elastic  instrument.  A  bougie  or 
catheter  should  be  passed  once  or  twice  a  week,  beginning  with 
the  largest  instrument  that  can  be  introduced  without  using  force. 
On  the  next  occasion  the  same  instrument  should  be  again  passed 
and  at  once  withdrawn,  and  the  next  size  substituted  for  it,  and 
allowed  to  remain  for  a  few  minutes.  In  this  way  the  urethra  is 
gradually  dilated  to  its  full  size.  Formerly  it  was  not  thought 
necessary  to  pass  a  larger  instrument  than  No.  12,  Fnglish  scale  ; 
now,  however,  ii:t\\  surgeons   are    satisfied  till   the  dilatation  has 


INTERNAL   URETHROTOMY.  713 

been  carried  to  the  size  of  No.  14.  To  prevent  recontraction  the 
patient  should  be  taught  to  pass  a  catheter  for  himself,  and  in- 
structed to  do  so  at  first  once  a  week,  then  every  month  or  six 
weeks,  and  subsequently  two  or  three  times  a  year,  according  to 
the  tendency  the  stricture  may  show  to  recontract. 

Rapid  or  continuous  dilaiation  is  very  useful :  i,  when  time 
is  an  object;  2,  when  much  difficulty  has  attended  the  introduc- 
tion of  an  instrument,  owing  to  the  tightness  of  the  stricture  or 
presence  of  a  false  passage  ;  3,  when  the  passage  of  an  instrument 
causes  great  pain,  irritation,  haematuria,  or  rigors  ;  4,  when  gradual 
dilatation  has  failed.  It  consists  in  tying  in  a  silver  cathether  for 
twenty  to  forty-eight  hours,  and,  on  removing  it,  tying  in  a  size 
or  two  larger,  and  so  on  till  the  urethra  is  fully  dilated.  The  in- 
strument should  not  fit  the  stricture  too  tightly,  and  its  end  should 
not  project  far  into  the  bladder.  It  is  better,  as  soon  as  the 
stricture  begins  to  yield,  to  substitute  a  gum-elastic  for  a  metal 
instrument.  This  method  necessitates  confinement  to  the  couch 
or  bed  for  ten  days  or  a  fortnight,  and  is  not  unattended  with 
risk.  It  frequently  causes  great  pain  ;  and  rigors,  fever,  urethritis, 
cystitis,  epididymitis,  and  ulceration  of  the  bladder  from  the  irri- 
tation of  the  point  of  the  catheter,  may  be  induced  by  it.  If  the 
catheter  merely  causes  pain,  opium  may  be  given,  or  the  urethra 
be  injected  with  a  solution  of  cocaine  ;  whilst  if  it  produces  rigors, 
fever,  cystitis,  etc.,  it  must  be  removed.  It  is  generally  believed 
that  the  mere  presence  of  the  catheter  in  the  stricture  causes  the 
absorption  of  the  inflammatory  material  in  the  submucous  tissue, 
and  that  this  result  is  not  effected  by  mechanical  stretching,  since 
a  catheter  that  does  not  fit  the  stricture  tightly  answers  better 
than  one  that  does,  and  causes  less  irritation.  The  method  of 
tying  in  a  catheter  will  be  learnt  by  every  student  whilst  dressing. 

Forcible  dilata'jion,  splitiing,  (jr  rupture,  has  been  much 
advocated  by  Mr.  Holt.  He  passes  through  the  stricture  an  in- 
strument consisting  of  two  parallel  blades  with  a  central  stem 
fixed  between  them,  and  then  over  this  stem  forces  a  tube  the 
size  of  the  urethra,  thus  separating  the  blades  and  splitting  or 
rupturing  the  stricture.  A  full-sized  catheter  is  then  passed.  The 
operation  is  not  unattended  with  danger,  and  is  more  liable  to  be 
followed  by  an  early  relapse  than  either  rapid  dilatation  or  in- 
ternal urethrotomy.  Indeed,  internal  urethrotomy  has  now  to  a 
great  extent  taken  its  place  in  the  treatment  of  linear,  contractile, 
and  penile  strictures  (the  strictures  to  which  splitting  is  said  to  be 
especially  adapted),  since  the  cicatrix  following  laceration  of  the 
tissues  is  much  more  prone  to  contract  than  that  following  a  clean 
cut. 

Internal  urethrotorh',  or  division  of  the  stricture  from  within 
30* 


714  DISEASES    OF    REGIONS. 

the  urethra,  is  an  excellent  operation,  but  should  only  be  under- 
taken when  the  simpler  and  safer  method  of  treatment  by  dilata- 
tion has  failed.  It  consists  of  making  a  clean  longitudinal  cut 
with  a  guarded  knife  completely  through  the  stricture,  and  sub- 
sequently in  keeping  the  edges  of  the  wound  apart  by  the  passage 
of  a  full-sized  bougie  till  the  ovoid  gap  thus  left  has  been  filled 
with  new  tissue — the  cicatricial  splice  of  the  x^merican  Surgeons. 
The  cicatrix  following  a  clean  cut  shows  much  less  tendency  to 
contract  than  a  cicatrix  following  a  laceration  or  rupture  ;  hence 
the  superiority  of  internal  urethrotomy  over  the  method  of  split- 
ting or  ruptare.  It  is  a  less  severe  operation  than  external 
urethrotomy,  and  when  a  urethrotome  can  be  passed  through  the 
stricture  should  generally  be  performed  in  preference  to  the  latter. 
The  cases  suitable  for  it  are  :  i.  Intractable  strictures  that  cannot 
be  dilated  beyond  the  size  of  a  No.  5  or  6  catheter.  2.  Strictures 
which  rapidly  recontract  after  dilating  instruments  are  discon- 
tinued. 3.  Cases  in  which  the  passage  of  instruments  is  con- 
stantly followed  by  retention  of  urine,  hsematuria,  rigors,  urethral 
fever,  or  other  constitutional  symptoms.  It  is  especially  ajipli- 
cable  to  strictures  within  three  or  four  inches  of  the  meatus. 
Anaesthesia  of  the  urethra  should  be  induced  by  injection  with  a 
20  per  cent,  solution  of  cocaine.  The  operation  may  be  done  by 
cutting — I.  From  before  backwards;  and  2.  From  behind  for- 
wards. The  latter  method  requires  that  the  stricture  should  be 
dilated  up  to  the  size  of  a  No.  4  or  5   catheter  to  enable  the 

Fig.  344. 


Tecvan's  urethrotome.     A,  staff;  n,  n,  stylct.s;  c,  olivary  bougie;  D,  kuife;  u,  knife  sheath. 

sheathed  blade  of  the  instrument  to  be  passed  through  it ;  the 
former  can  be  done  if  the  stricture  will  admit  a  No.  2  catheter. 
There  are  many  ways  of  performing  both  methods.  The  follow- 
ing appear  to  be  the  best : — 

1 .  Internal  division  of  the  stricture  from  before  backwards. — If 
the  stricture  is  sufficiently  near  the  meatus  it  may  be  simply 
divided  by  a  straight  blunt-pointed  bistoury ;  otherwise  Teevan's 


INTERNAL    URETHROTOMY.  715 

urethrotome  (Fig.  344),  which  is  a  modification  of  Maisonneuve's, 
or  Berkley  Hill's  instrument,  should  be  used.  Teevan's  consists  of 
a  slender  staff  a  with  an  open  slot  running  along  it  to  within  two 
inches  of  its  head.  Within  this  staff  is  fitted  a  stylet  b.  The 
slender  olivary  bougie  c  is  first  wriggled  through  the  stricture  into 
the  bladder ;  the  staff  a  is  then  screwed  on  to  the  bougie  and 
made  to  follow  it,  the  bougie  coiling  up  in  the  bladder.  When 
the  stylet  is  withdrawn  the  urine  will  escape,  if  the  instrument  has 
passed  into  the  bladder  and  not  into  a  false  passage.  The  knife 
D,  covered  by  the  sheath  e,  is  then  placed  inside  the  slot,  and  the 
stem  of  the  sheathed  knife  is  pushed  down  to  the  stricture.  The 
knife  is  next  protruded  to  half  an  inch,  and  then  withdrawn  in  its 
sheath,  which  is  pushed  forward  to  see  if  the  stricture  is  com- 
pletely divided.  If  it  be  not,  the  process  is  repeated.  Teevan 
divides  the  roof  of  the  urethra  to  avoid  the  bulb,  and  the  conse- 
quent danger  of  haemorrhage  from  that  structure.  As  soon  as  the 
canal  is  free  from  one  end  to  the  other,  he  pass  a  full-sized  silver 
catheter  to  prove  that  the  calibre  of  the  urethra  has  been  restored, 
and  completely  empties  the  bladder.  He  advises  that  a  catheter 
should  not  be  left  in,  and  no  instrument  passed  for  four  days. 

Fig.  345. 


Thompson's  modification  of  Civiale's  urethrotome. 

2.  Internal  divisio)i  of  the  stricture  from  behind  fojivards. —  ((?) 
Sir  Henry  Thompson  uses  a  modification  of  Civiale's  urethrotome 
(Fig.  345).  He  first  dilates  the  stricture  to  the  size  of  No.  4  or  5 
bougie ;  then  passes  the  bulb  of  the  urethrotome,  which  contains 
the  guarded  knife,  about  a  third  of  an  inch  beyond  the  stricture ; 
protrudes  the  knife  by  a  suitable  arrangement  in  the  handle,  and 
draws  it  firmly  towards  the  meatus  for  about  an  inch  and  a  half, 
dividing  the  stricture  along  the  floor  of  the  urethra,  and  a  little  of 
the  healthy  mucous  membrane  at  each  end  of  it.  He  then  passes 
a  No.  14  or  16  bougie,  and  if  this  is  felt  to  be  held  at  any  point 
re-introduces  the  urethrotome,  and  divides  what  remains  of  the 
stricture.  A  No.  12  gum-elastic  catheter  is  then  tied  in  for 
twenty-four  to  forty-eight  hours,  {b)  Dr.  Otis  uses  what  he 
calls  a  dilating  urethrotome  (Fig.  346).  It  is  introduced  beyond 
the  stricture,  the  screw  at  the  handle  is  turned,  dilating  the  in- 
strument up  to  a  millimetre  or  two  beyond  the  normal  calibre  of 
the  stricture,  in  order  to  make  the  latter  completely  salient. 
Then  the  blade  is  drawn  through  the  stricture,  dividing  it  from 


710 


DISEASES   OK   REGIONS. 


behind  forwards.  Otis  claims  that  when  the  stricture  has  been 
completely  divided,  re-contraction  does  not  occur.  This,  how- 
ever, would  appear  to  be  contrary  to  the  experience  of  Surgeons 
generally,  the  stricture  returning  (though  less  rapidly),  as  it  does 
after  all  methods  of  treatment,  if  a  bougie  is  not  occasionally 
passed. 

For  strictures  in  front  of  the  scrotum,  internal  urethrotomy  is  a 
very  successful  operation;  but  in  deeper  situations  it  has  been 
followed  by  abscess,  severe  hcemorrhage,  extravasation  of  urine, 

Fig.  346. 


Otis'  urethrotome. 


cystitis,  nephritis,  and  pyaemia.     It  would  appear  to  be  attended 
with  a  mortality  ranging  from  i  to  3  per  cent. 

External  urethrotomy,  or  opening  the  urethra  from  the 
perineum,  may  be  required  for  two  distinct  conditions,  i.  For 
certain  strictures  which,  though  pervious  to  instruments,  are  of 
an  intractable  nature.  Here  the  operation  known  as  Syme's 
should  be  done.  2.  For  strictures  through  which,  even  after  the 
utmost  perseverance,  an  instrument  cannot  be  passed.  In  these 
cases  the  stricture  may  be  divided  by  VVheelhouse's  modification 
of  the  old  method  of  perineal  section ;  or  the  urethra  may  be 

Fig.  347. 


Syme's  staff. 


opened  by  Cock's  method,  /.  c,  behind  the  stricture  at  the  apex 
of  the  prostate,  and  the  siricture  left  undivided  in  the  hope  that, 
relieved  from  the  pressure  and  irritation  of  the  urine,  it  may  be- 
come pervious  to  instruments. 

Syme's  nie/hod  of  external  urethrotomy  or  perineal  section. — 
Syme  advises  this  operation  for — i,  irritable,  and  2,  contractile 
strictures  "that  are  indomitable  by  the  ordinary  means  of  treat- 
ment."    For  such,  however,  internal  urethrotomy  is  now  gene- 


INTERNAL    URETHROTOMY,  717 

rally  preferred,  and  Syme's  operation  reserved  for  3,  indurated 
and  cartilaginous  strictures,  complicated  by  intractable  perineal 
fistulse  where  dilatation  has  failed.  Introduce  Syme's  shouldered 
staff  (Fig.  347)  so  that  the  slender  part  passes  through  the  strict- 
ure into  the  bladder,  and  the  shoulder  of  the  thicker  part  rests 
against  the  face  of  the  stricture.  Place  the  patient  in  the  litho- 
tomy position,  and  make  an  incision  one  inch  and  a  quarter  long 
through  the  middle  line  of  the  perineum  over  the  stricture. 
Having  felt  the  staff  distinctly  in  the  wound,  take  it  in  the  left 
hand,  "  and  guarding  the  knife  with  the  right  forefinger,  insert  its 
point  into  the  groove  on  the  bladder  side  of  the  stricture,  and 
divide  the  stricture  from  behind  forward.  When  completely  di- 
vided, the  thicker  part  of  the  staff  can  be  pushed  on  into  the 
bladder."  A  full-sized  catheter  should  be  tied  in  for  twenty-four 
hours.  The  difficulties  attending  Syme's  operation  are — i,  to  be 
sure  that  the  staff  is  in  the  bladder,  and  not  in  a  false  passage  ; 
and  2,  to  pass  a  catheter  afterwards.  These  are  obviated  by  the 
modification  suggested  by  Teevan.  He  advises  a  catheter-staff 
with  a  groove  on  its  convexity,  along  which  the  knife  can  be  run 
to  divide  the  stricture.  When  introduced,  it  is  known  to  be  in 
the  bladder  by  the  escape  of  urine  on  removing  the  stylet.  A 
bougie  is  then  screwed  on  to  its  end,  and  a  gum-elastic  railway 
catheter  is  passed  over  the  bougie  and  staff  till  arrested  by  the 
stricture,  and  is  there  fixed  by  a  screw.  When  the  stricture  is 
thought  to  be  divided,  the  catheter  is  advanced  over  the  staff; 
and  if  all  is  divided,  will  pass  on  into  the  bladder.  The  catheter- 
staff  can  now  be  withdrawn,  and  the  catheter,  if  desired,  left  in 
the  bladder.  Syme's  operation  is  very  useful,  but  like  other 
methods,  is  liable  to  be  followed  by  recontraction  if  a  bougie  is 
not  occasionally  passed. 

Perineal  section  must  not  be  confounded  with  Syme's  opera- 
tion, to  which  this  term  is  sometimes  apphed.  The  older  opera- 
tions of  perineal  section  were  performed  by  cutting  into  the 
urethra  either  in  front  of  or  behind  the  stricture,  and  then  trying 
to  divide  the  stricture  without  a  guide.  They  were  the  most 
difficult  operations  in  Surgery.  The  stricture  was  often  missed 
altogether  and  an  incision  made  by  its  side,  and  the  greatest  dif- 
ficulty was  experienced  in  finding  the  proximal  end  of  the  ure- 
thra. Indeed,  after  a  long  search  the  Surgeon  had  ofteai  the 
mortification  of  having  to  send  the  patient  back  to  bed  without 
having  succeeded  in  reaching  the  bladder.  These  difficulties 
have  to  a  great  extent  been  overcome  by  Mr.  Wheelhouse,  who, 
instead  of  cutting  down  upon  the  end  of  the  staff  on  the  face  of 
the  stricture,  opens  the  urethra  half  an  inch  in  front  of  it,  and 
passes  a  director  through  the  opening  thus  made  in  the  urethra 
into  the  stricture  and  divides  the  latter, 


7i8 


DISEASES   OF   REGIONS. 


Wheelhouse's  modification  of  perineal  section. — Pass  Wheelhouse's 
staff  (Fig.  348),  with  the  groove  downwards,  to  the  stricture. 
Place  the  patient  in  the  Hthotomy  position  with  the  pelvis  raised 
so  that  light  may  fall  into  the  wound.  Make  an  incision  in  the 
middle  line  of  the  perineum,  and  open  the  urethra  on  the  groove, 

Fig.  348. 


Wheelhouse's  staff. 

(not  on  the  point  of  the  staff)  so  as  to  be  half  an  inch  \x\  front  of 
the  stricture.  Seize  the  edges  of  the  healthy  urethra  on  each  side 
by  artery  forceps,  and  hold  them  apart.  Withdraw  the  staff  a 
little,  turn  it  so  that  the  groove  looks  toward  the  pubes,  and  catch 
up  the  upper  angle  of  the  opened  urethra  by  the  hooked  end. 
The  urethra  is  thus  held  open  at  three  points  (Fig.  349).     Search 


Wheelhouse's  method  of  opening  urethra.      (Hryant's  Surgery.) 

for  the  stricture,  and  pass  a  slender  probe-pointed  director 
through  it  into  the  bladder.  Divide  the  stricture  with  a  probe- 
pointed  bistoury  run  along  the  groove  in  the  director.  Pass  the 
point  of  the  j)robe-gorget  (F"ig.  350)  along  the  groove  of  the  di- 
rector towards  the  bladder,  dilating  the  divided  stricture.  Intro- 
duce a  gum-elastic  catheter  from  the  meatus  into  the  wound,  and 
guide  it  by  the  gorget  into  the  bladder.  Withdraw  the  gorget, 
and  retain  the  catheter  in  the  urethra  for  three  or  four  days. 
The  catheter  should  allow  a  catgut  bougie  to  pass  through  it  to 
act  as  a  guide  when  it  has  to  be  changed. 


URETHRAL    OR   URINARY    ABSCESSES.  719 

Cock's  operalion  of  perineal  section,  or  tapping  the  dilated 
urethra  at  the  apex  of  the  prostate  "unassisted  by  a  guide  staff." 
Secure  the  patient  in  the  hthotomy  position.  Pass  the  left  fore- 
finger into  the  rectum,  and  place  its  points  on  the  apex  of  the 
prostate.  Plunge  a  double-edged  scalpel  (Cock's  knife)  boldly 
into  the  median  line  of  the  perineum,  and  carry  it  towards  the  tip 
of  the  finger  in  the  rectum.  Enlarge  the  incision  by  an  upward 
and  downward  movement  of  the  knife,  but  do  not  withdraw  it. 
When  the  point  is  felt  near  the  tip  of  the  finger,  pass  it  onwards 
into  the  urethra.  Withdraw  the  knife,  keep  the  finger  in  the  rectum, 
and  guide  a  probe-pointed  director  into  the  bladder.  Withdraw 
the  finger  from  the  rectum,  and  pass  a  cannula  along  the  director 
into  the  bladder,  and  tie  it  in  for  a  few  days.     This  appears  to  be 

Fig.  350. 


Wheelhouse's  probe-gorget. 

a  good  operation  for  impervious  stricture  with  fistulse  and  much 
induration  of  the  perineum,  and  is  held  in  considerable  favor  by 
some  of  Guy's  Surgeons.  For  such  strictures,  however,'  Wheel- 
house's  operation  is  more  generally  performed. 

Electrolysis  has  recently  been  advocated  for  stricture,  and 
several  successful  cases  in  this  country  have  been  reported  by  the 
late  Dr.  Stevenson  and  Mr.  Bruce  Clarke.  It  consists  in  passing 
a  catheter-electrode  down  to  the  face  of  the  stricture,  connecting 
it  with  the  battery,  and  applying  the  other  electrode  to  some 
other  part  of  the  body.  It  is  believed  to  act  by  causing  some 
chemical  change  in  the  cicatricial  tissue,  thus  leading  to  its  ab- 
sorption. It  has  been  employed  for  stricture  where  an  instrument 
after  persistent  attempts. cannot  be  passed,  and  as  a  substitute  in 
some  cases  for  dilation.  Sufficient  time  has  not  elapsed  to  judge 
of  the  results  that  may  be  expected  from  this  method  of  treat- 
ment. It  is  certainly  not  unattended  with  danger — extravasation 
of  urine  and  even  death  having  followed  its  employment. 

Urethral  or  urinary  abscesses  may  occur  at  any  part  of  the 
urethra,  but  the  most  common  situation  is  in  the  perineum. 
Cause. — They  are  most  often  formed  in  connection  with  stricture, 


720  DISEASES    OF    REGIONS. 

and  are  then  due  to  ulceration  and  local  extravasation  of  urine 
behind  the  seat  of  obstruction.  The)'  may  also  result  from  injury 
inflicted  either  from  without  or  from  within,  as  passing  an  instru- 
ment along  the  urethra,  or  the  impaction  of  a  calculus  ;  or  they 
may  occur  during  an  attack  of  gonorrhosa  from  inflammation  ex- 
tending to  one  of  the  urethral  follicles,  or  to  Cowper's  glands.  The 
sis^/is  of  a  urethral  abscess  in  the  perineum,  its  most  common  sit- 
uation, are  the  presence  of  a  hard,  brawny,  deeply- seated  swelling, 
generally  beginning  in  the  middle  line  just  in  front  of  the  anus, 
and  as  it  increases  in  size,  making  its  way  to  one  or  other  side  of 
the  perineum  in  the  direction  of  the  groin.  At  first,  while  the 
pus  is  bound  down  by  deep  fascia,  there  is  no  fluctuation,  and 
it  is  only  as  it  approaches  the  surface  that  this  sign  of  abscess  can 
be  detected.  The  abscess  is  attended  with  throbbing  pain,  often 
with  sharp  constitutional  disturbance,  and  occasionally  with  a 
rigor  ;  it  may  also  cause  retention  of  urine.  Tj-eatincnt. — Fluctua- 
tion must  not  be  waited  for,  but  a  catheter  passed  down  the 
urethra,  and  a  free  incision  made  in  the  median  line  of  the  peri- 
neum into  the  swelling.  If  the  abscess  is  not  opened,  it  may 
break  externally  on  the  perineum,  or  it  may  burrow  amongst  the 
tissues  and  break  into  the  rectum  ;  and  if  not  already  in  connec- 
tion with  the  urethra,  as  when  the  abscess  forms  external  to  it,  it 
may  break  into  that  canal. 

Urinary  fistula  are  generally  the  result  of  urinary  abscess  in 
connection  with  stricture  of  the  urethra.  They  may  also  be  due 
to  wounds  of  the  urethra,  made  accidentally,  or  by  surgical  opera- 
tion, or  to  ulceration  following  impaction  of  a  calculus.  They  are 
commonly  divided  into  three  kinds: — i.  The  perineal;  2,  the 
scrotal ;  and  3,  the  penile. — The  perineal  may  be  single  or  mul- 
tiple ;  the  scrotal  are  nearly  always  multiple  ;  and  the  penile 
single.  In  long-standing  cases  the  fistulje  may  burrow  among  the 
tissues  of  the  groin,  nates,  and  thighs,  and  may  even  open  into 
the  rectum. 

Treatment. — When  due  to  stricture,  the  fistulee  will  generally 
readily  heal  when  the  stricture  is  cured  and  a  free  natural  pass- 
age is  established  for  the  escape  of  urine.  Should  they  not  do 
so — I.  h perineal fistu/a  when  small  may  be  induced  to  close  by 
passing  a  soft  catheter  to  prevent  the  contact  of  urine  whenever 
the  patient  micturates,  or  l)y  inserting  into  the  fistula  a  hot  wire 
or  a  ])robe  coated  with  silver  nitrate.  If  these  means  fail,  the 
edges  of  the  fistula  may  be  pared  and  brought  together  by 
sutures.  When  the  parts  are  indurated  and  the  stricture  is  of  the 
cartilaginous  kind,  external  urethrotomy  and  laying  open  of  the 
fistulas  should  be  practised.  2.  ^SVri^/^/yf.f/'///*^' nearly  always  re- 
quire freely  laying  open,  and  when  secondary  fistulse  extend  to 


EXTRAVASATION   OF   URINE.  72 1 

the  groin  or  buttock  they  should  also  be  treated  in  this  way.  3. 
Penile  fisiulce  when  latge,  and  especially  when  the  result  of  slough- 
ing consequent  upon  the  impaction  of  a  calculus,  usually  require 
a  plastic  operation. 

Extra VASAiiON  of  urine  is  commonly,  though  not  always,  the 
result  of  stricture,  and  is  then  due  either  to  the  dilated  urethra 
behind  a  stricture  ulcerating  and  giving  way,  or  to  a  lacunar  ab- 
scess bursting  into  the  urethra.  In  either  case,  the  urine  is 
forced  by  the  contraction  of  the  bladder  into  the  surrounding 
cellular  tissue.  The  urethra  may  give  way  ( i )  in  front  of  the 
anterior  layer,  (2)  between  the  two  layers,  and  (3)  behind  the 
posterior  layer  of  the  triangular  ligament.  In  the  first  and  by  far 
the  most  common  situation,  it  is  the  bulbous  portion  of  the  ure- 
thra that  gives  way.  Here  the  urine  is  prevented  from  passing 
— I,  backwards  into  the  pelvis  by  the  anterior  layer  of  the  tri- 
angular ligament  being  attached  to  the  rami  of  the  pubes  and 
ischium  and  sub-pubic  ligament;  2,  downwards  into  the  ischio- 
rectal fossa  by  the  anterior  layer  of  the  triangular  ligament  being 
continuous  around  the  transverse  perineal  muscle  with  the  deep 
layer  of  the  superficial  fascia  of  the  perineum  ;  3,  laterally,  on  to 
the  thighs  by  the  deep  layer  of  the  superficial  fascia  of  the  peri- 
neum being  attached  to  the  rami  of  the  pubes  and  ischium.  Hence 
it  passes  in  the  middle  line  into  the  cellular  tissue  of  the  scrotum 
and  penis,  and  laterally  on  to  the  abdomen,  where  it  is  prevented 
from  passing  down  the  thigh  by  the  deep  layer  of  the  superficial 
fascia  of  the  groin  (which  is  continuous  with  the  deep  layer  of  the 
superficial  fascia  of  the  perineum)  being  attached  along  the  line 
of  Poupart's  ligament.  When  the  membi-aneous  portion  of  the 
urethra  is  ruptured,  the  urine  is  confined  at  first  between  the  two 
layers  of  the  triangular  ligament,  and  if  not  let  out  will  make  its 
way  (i)  forwards,  through  the  anterior  layer,  and  take  the  course 
as  given  above;  or  rarely  (2)  backwards,  through  the  posterior 
layer,  and  then,  as  when  the  urethra  gives  way  behind  the  poster- 
ior layer,  will  make  its  way  around  the  neck  of  the  bladder,  and 
will  be  almost  inevitably  fatal.  Wherever  the  urine  spreads,  it 
causes  inflammation  and  sloughing. 

Symptoms. — The  history  of  a  case  of  extravasation  is  not  un- 
commonly as  follows  :  A  patient  with  a  tight  stricture  is  strain- 
ing to  pass  water;  he  feels  something  give  way,  experiences  a  sen- 
sation of  relief,  and  perhaps  owing  to  the  tension  being  removed 
by  some  urine  being  forced  into  the  cellular  tissue,  the  super- 
added spasm  for  a  time  ceases,  and  a  few  ounces  of  urine  are 
passed  through  the  urethra.  In  half  an  hour  or  so  a  pricking  or 
burning  sensation  is  felt  in  the  perineum,  soon  followed  by  pain, 
and  by  rapidly  increasing  swelling  of  the  perineum,  scrotum  and 
31 


722  DISEASES    OF    REGIONS. 

penis.  If  the  urine  is  not  let  out  by  timely  incisions  the  swelling 
extends  to  the  groin,  and  in  some  cases  has  been  known  to  reach 
as  high  as  the  axilla.  The  skin  now  appears  dusky  or  purplish- 
red  and  oedematous,  and  gangrene  and  sloughing  of  the  infiltrated 
tissues  rapidly  ensue.  The  absorption  of  the  septic  products 
gives  rise  to  constitutional  disturbance  and  fever,  which  though  it 
may  at  first  run  high,  soon  assumes  a  low  typhoid  character,  and 
the  patient,  especially  if  the  subject  of  chronic  kidney  disease, 
frequently  sinks  into  a  comatose  state  and  dies.  When  the  ex- 
travasation occurs  between  the  two  layers  of  the  triangular  liga- 
ment, it  may  remain  localized,  giving  rise  to  a  hard  circumscribed 
swelling  in  the  perineum,  which  may  slowly  make  its  way  towards 
the  scrotum ;  and  lastly,  when  the  extravasation  occurs  behind 
the  posterior  layer  of  the  triangular  ligament  and  the  urine  is  ex- 
travasated  into  the  pelvic  cellular  tissue,  the  symptoms  resemble 
those  of  extra-peritoneal  rupture  of  the  bladder. 

Treatment. — A  catheter  should  be  passed  into  the  bladder,  or 
where  this  is  impossible,  down  to  the  stricture,  and  in  either  case 
a  free  incision  in  the  middle  line  of  the  perineum  extending  into 

the  urethra  made  on  the  catheter. 
P"^-  351-  Free    incisions   through    the    skin 

'  -^  •  ("  ..     -'^      of  the  scrotum,  penis  and  groins, 

.  '      in  fact,   wherever    the   urine    has 
j      penetrated,    should     hkewise     be 
•  ./      made    to    allow    of    its    draining 
'>^-  '        away,  and  the  wounds  rendered  as 
/  far  as  possible  aseptic  by  the  free 

application    of  iodoform  or  other 
antiseptics.    The  patient's  strength 
'  at    the    same  time    must    be    sup- 

ported by   fluid   nourishment  and 
stimulants ;    whilst    opium    should 
be    given,  unless   contra-indicated 
^''  on  account  of  kichiey  disease. 

Calculus  impacto'J  in  urethra.    (St.  Bar-            Q.rr^^TT-  txr  1  in- TiurTuia  a         A   ci-r,in 
tholomew's  Hospital  -Museum.)  bfONE  IN  IHE  UREIHRA. A  Small 

calculus  or  fragment  of  one  may 
become  impacted  in  any  part  of  the  urethra,  but  most  frequently 
in  the  membraneous  portion  (F'ig.  351),  or  just  within  the  meatus. 
When  sharp  and  angular  it  causes  much  pain,  and  when  large 
enough  to  obstruct  the  urethra  gives  rise  to  retention,  and,  if  not 
soon  removed,  to  ulceration,  followed  by  extravasation  of  urine. 
Treatment. — If  far  forward,  it  may  often  be  expelled,  whilst 
straining  to  ])ass  water,  by  holding  the  meatus  and  suddenly  let- 
ting go  ;  or  gentle  manipulation,  aided,  if  necessary,  by  incision 
of  the  meatus,  may  suffice.     I-'.xtraction  by  the  urethral  forceps 


RETENTION   OF   URINE.  723 

should  next  be  tried  (Figs.  352  and  353),  and  this  failing,  a  free 
incision  over  the  stone  must  be  made.  Thus,  if  impacted  in  the 
membraneous  portion,  it  should  be  removed  through  an  incision 
in  the  middle  line  of  the  perineum  ;  if  in  the  penile  portion  just 
in  front  of  the  scrotum,  it  should  be  pushed  back  if  possible  into 
the  membraneous  portion  and  removed  through  the  perineum,  as 
an  incision  in  the  penile  portion  cf  the  urethra  is  apt  to  be  fol- 

FiG.  352. 


Urethral  forceps  (Arnold's). 


lowed  by  a  fistula,  and  should,  if  possible,  be  avoided.  If  com- 
pelled to  incise  the  penile  urethra  the  incision  should  be  free,  so 
as  to  prevent  laceration  of  the  tissues  in  extracting  the  stone. 
The  edges  of  the  wound  should  then  be  united  by  suture,  and  a 
soft  catheter  tied  in  the  urethra  for  a  few  days  till  the  incision 
has  healed. 

Vascular  tumors  are  much  more  frequent  in  the  female  than 
in  the  male  urethra.  In  the  female,  they  occur  as  small  florid 
excrescences  usually  situated  about  the  entrance  of  the  urethra, 

Fig.  353. 


Hogan's  urethral  forceps. 

often  surrounding  it  like  a  ring  and  perhaps  extending  some  dis- 
tance up  it.  They  give  rise  to  increased  frequency  of  micturition, 
pain  during  the  act,  and  intermittent  attacks  of  haemorrhage,  thus 
somewhat  simulating  the  symptoms  of  a  calculus  ;  but  inspection 
will  at  once  reveal  the  nature  of  the  affection.  Ti-eatmeni. — 
Ligature,  or  the  applicadon  of  nitric  acid  or  the  therrao-cautery, 
generally  suffices  for  their  cure. 

Retention  of  urine,  or  inabihty  to  pass  water,  must  be  dis- 
tinguished from  suppression  of  urine,  in  which  none  is  secreted  by 
the  kidneys,  Crt;//jrd'.^Retention  may  depend  upon  either  ^a) 
obstruction  to  the  outflow  of  urine  from  the  bladder,  or  (/')  in- 
ability of  the  bladder  to  expel  its  contents  consequent  upon 
atony  of  its  muscular  coat  or  paralysis.     Retention,  therefore,  is 


724  DISEASES   OF   REGIONS. 

a  symptom  of  several  diseases,  i.  In  the  old,  it  is  commonly  due 
to  enlarged  prostate  with  superadded  congestion,  combined  with 
atony  of  the  bladder  from  over-distension.  2.  In  adii/t  men  it 
may  be  due  to  organic  stricture  with  temporary  spasm  of  the  un- 
striped  muscular  fibres  of  the  urethra,  or  to  congestion  of  the 
mucous  membrane  owing  to  gonorrhoea,  a  drinking  bout,  or  cold 
and  wet.  3.  In  -ivomen  it  may  be  the  result  of  hysteria,  or  the 
pressure  of  an  enlarged  uterus  or  other  pelvic  tumor,  or  of  the 
foetal  head  in  parturition.  4.  In  children  it  is  commonly  caused 
by  an  impacted  calculus  or  ligature  of  the  penis,  and  more  rarely 
by  phimosis.  5.  At  all  ages  and  in  both  sexes  it  may  be  due  to 
reflex  spasm  after  an  operation  on  the  rectum,  shock  following 
any  severe  injury  or  operation,  a  tumor  in  the  neck  of  the  bladder 
or  urethra,  and  an  abscess  in  an}'  part  of  the  urethra.  It  may  also 
be  due  to  paralysis  consequent  upon  disease  or  injury  of  the  brain 
or  spinal  cord,  and  to  atony  of  the  muscular  coat  of  the  bladder. 
In  the  two  latter  conditions,  however,  after  the  bladder  has  be- 
come distended  and  will  hold  no  rnore,  the  excess  of  urine  pas- 
sively overflows,  dribbling  constantly  away  ;  and  this  condition  of 
false  incontinence  must  be  distinguished  from  true  incontinence, 
in  which  the  urine  runs  away  from  the  bladder  as  fast  as  it  is 
secreted  by  the  kidneys. 

Symptoms  and  signs. — When  retention  has  come  on  slowly,  as 
from  the  gradual  contraction  of  an  organic  stricture,  there  may  be 
but  little  local  pain  and  no  constitutional  disturbance,  even  al- 
though the  bladder  may  be  distended  by  many  ounces  of  urine. 
Where,  however,  it  is  produced  suddenly,  there  is  usually  great 
pain  followed  by  severe  constitutional  symptoms — a  small  and 
frequent  pulse,  a  dry  and  brown  tongue,  and  perhaps  delirium, 
sym])toms  probably  due  to  the  sudden  check  to  secretion  by  the 
kidneys,  and  to  the  stretching  of  the  bladder.  The  bladder  it- 
self, unless  greatly  hypertrophied  and  contracted,  rises  out  of  the 
pelvis,  and  may  be  felt  as  a  distinct  tumor,  dull  to  percussion,  and 
at  times  extending  as  high  as  the  umbilicus,  or  in  extreme  cases 
even  to  the  ensiform  cartilage.  The  patient,  unless  drunk,  usually 
com])lains  of  inability  to  pass  water.  When,  however,  the  blad- 
der has  become  gradually  distended  and  urine  is  passively  flowing 
away,  he  may  complain  of  inability  to  hold  his  water,  and  be 
quite  unaware  that  the  bladder  is  full  and  may  object  to  have  a 
catheter  passed  till  the  condition  has  been  explained.  The  pres- 
ence of  a  swelling  in  the  abdomen,  and  the  flowing  of  urine 
through  the  catheter  immediately  after  the  patient  has  passed 
water  and  believes  that  he  has  emptied  his  bladder,  should  serve 
for  the  diagnosis.  '  \\\  supi)ression,  the  bladder  is  found  empty  on 
passing  a  catheter. 


RETENTION    OF    URINE.  725 

Resua's  of  retention. — If  the  bladder  is  soon  relieved  no  appar- 
ent harm  maj  ensue.  If  neglected,  hov/ever,  the  over-distension 
may  lead  to — i,  atony  of  the  muscular  coat-  2,  cystitis;  3,  neph- 
ritis ;  4,  rupture  of  the  urethra  behind  the  obstruction  :  5  (rarely), 
rupture  of  the  bladder  itself;  and  6,  passive  overflow  of  urine,  the 
bladder  remaining  full. 

Treatment. — The  distended  bladder  must  be  relieved,  and  if 
the  distension  is  extreme  and  the  symptoms  urgent,  at  once. 
The  way  of  doing  this  will  vary  according  to  the  cause,  and  will 
be  considered  under  the  following  heads  : 

1.  Retention  from  spasm  of  the  jinstriped fibres  surrounding  the 
urethra,  sometimes  called  spasmodic  stricture.  Spasm  is  rarely, 
if  ever,  sufficient,  alone,  to  cause  retention.  Generally  some 
slight  organic  narrowing  of  the  urethra  is  also  present.  The  usual 
history  of  retention  from  spasm  is  a  drinking  bout,  or  exposure 
to  cold  or  wet  in  a  gouty  or  rheumatic  subject ;  while  on  careful 
questioning,  the  patient  admits  that  the  stream  has  been  noticed 
to  be  small  or  forked,  or  that  a  similar  attack  of  retention  has 
previously  occurred.  If  the  retention  has  existed  for  some  time, 
and  there  is  much  pain  and  considerable  distension  of  the  blad- 
der, a  full-sized  flexible  catheter  (No.  8  or  9)  should  be  passed, 
if  necessary  under  chloroform.  When,  however,  the  symptoms 
are  not  urgent,  and  an  instrument  has  never  been  passed,  a  hot 
bath  and  a  full  dose  of  tincture  of  opium  will  generally  suffice. 
In  retention  due  to  spasm  following  operations,  a  well-oiled  soft- 
rubber  catheter  should  be  passed. 

When  the  spasm  is  associated  with  a  severe  organic  stricture 
other  means  may  have  to  be  taken.  See  Treatment  of  Retention 
from  Organic  Stricture. 

2.  Retention  from  congestion  of  t]u  mucous  }nembrane  of  the 
urethra,  sometimes  known  as  congestive  stricture.  Congestion, 
hke  spasm,  is  seldom  sufficient  of  itself  to  produce  retention;  and 
is  nearly  always  associated  with  at  least  a  shght  organic  stricture 
or  with  some  enlargement  of  the  prostate.  It  is  usually  the  re- 
sult of  gonorrhoea,  or  other  conditions  causing  inflammation  of 
the  urethra.  The  treatment  is  similar  to  that  of  retention  from 
spasm. 

3.  Retention  from  hypertrophy  of  the  prostate  only  occurs  after 
middle  life.  It  is  then  generally  due  to  congestion  induced  by 
cold,  the  abuse  of  alcohol,  etc.,  causing  the  already  existing  obstnic- 
tion  to  become  complete.  First,  try  to  pass  a  No.  9  French  single 
coude  catheter  (Fig.  i'^'^^,  then  a  double  coude  (Fig.  339),  and 
these  failing,  a  gum-elastic  catheter  with  a  large  curve.  Should 
the  point  hitch  at  the  middle  lobe  of  the  prostate,  withdrawing 
the  stylet  for  half  an  inch  will  cause  the  end  to  slightly  tilt  up. 


726  DISEASES   OF   REGIONS. 

and  it  will  then  often  readily  glide  into  the  bladder.  If  not  suc- 
cessful in  this  way  the  silver  prostatic  or  the  beaked  catheter  must 
next  be  tried,  but  serious  mischief  may  be  done  by  these  instru- 
ments unless  the'greatest  gentleness  is  used.  They  should  never 
be  employed  until  other  forms  have  failed.  If  a  catheter  passes 
easily  it  may  be  withdrawn  after  the  bladder  is  relieved  ;  but  if  passed 
with  difficulty  it  had  better  be  left  in,  as  more  harm  may  be  done 
by  having  to  pass  it  again  than  by  leaving  it  in  situ.  When  the 
bladder  is  greatly  distended  all  the  urine  should  not  be  drawn  off 
at  once,  lest  syncope  be  induced.  A  catheter  failing,  the  reten- 
tion may  be  relieved  by  :  i,  puncture  above  the  pubes  ;  2,  punct- 
ure through  the  rectum  ;  and  3,  forcing  a  catheter  through  the 
prostate  {tiinnellini:^).  The  first  method  is  decidedly  the  best. 
The  second  is  seldom  applicable,  as  the  enlargement,  as  a  rule, 
leaves  no  room  between  the  prostate  and  the  pouch  of  peritoneum 
for  puncture,  which,  if  attempted,  will  probably  wound  the  peri- 
toneum. The  third  method  is  attended  with  extreme  danger,  and 
is  seldom  practised  at  the  present  day. 

4.  Retention  from  organic  stricture. — The  symptoms  and  diag- 
nosis of  stricture  have  already  been  described.  Here  only  need  be 
mentioned  the  treatment  to  be  adopted  in  cases  of  retention  from 
this  cause.  An  endeavor  should  first  be  made  to  pass  a  catheter, 
if  necessary  under  an  anaesthetic.  If  this  fails,  and  the  symptoms 
are  not  urgent,  a  hot  bath  and  a  full  dose  of  tincture  of  opium 
may  be  given,  and  another  trial  made  in  a  few  hours.  Where, 
however,  there  are  signs  of  grave  kidney  mischief,  opium  must  be 
withheld  or  given  with  great  caution.  Should  these  means  not 
succeed,  or  if  from  the  first  the  symptoms  are  urgent,  one  of  the 
following  methods  may  be  resorted  to,  viz.;  i,  Aspiration  or 
puncture  of  the  bladder  above  the  pubes;  2,  Wheelhouse's  oper- 
ation ;  3,  Puncture  of  the  bladder  through  the  rectum  ;  4,  Cock's 
operation  of  opening  the  urethra  behind  the  stricture  through  an 
incision  in  the  perineum;  and  5,  Forcing  a  catheter  into  the 
bladder.  The  last  method  is  highly  objectionable,  and  should  on 
no  account  be  [)ractised.  Of  the  other  methods  aspiration  above 
the  pubes,  repeated,  if  necessary,  should  the  stricture  not  quickly 
yield  after  the  s])Tsm  has  been  removed  by  emptying  the  bladder 
and  thus  reducing  the  tension,  is  in  my  oi)inion  the  best.  Punct- 
ure through  the  rectum  is  strongly  recommended  by  some  Sur- 
geons ;  but  it  is  open  to  the  objection  that  suppuration  between 
the  bladder  and  rectum,  extravasation  of  urine,  and  a  permanent 
recto-vesical  fistula,  are  liable  to  follow,  to  say  nothing  of  the  an- 
noyance to  the  patient  from  the  presence  of  the  cannula  in  the 
rectum,  and  the  excoriation  of  the  parts  by  the  urine,  which,  not- 
withstanding care,  is  apt  to  occur.     The  vas  deferens,  moreover. 


PUNCTURE    OF   THE    BLADDER   THROUGH    THE    RECTUM.  727 

may  be  injured,  and  atrophy  of  the  testicle  ensue.  Cock's  operation 
is  difficult  to  perform,  and  does  not  appear  to  possess  any  advantage 
over  aspiration  or  puncture  above  the  pubes.  Should  the  passage 
of  a  catheter  not  be  effected  after  the  bladder  has  been  aspirated 
on  several  occasions,  Wheelhouse's  operation  should  be  under- 
taken. Aspiration,  though  as  a  rule  attended  with  excellent  re- 
sults, is  not  absolutely  free  from  danger.  Thus  it  should  not  be 
practised  when  the  urine  is  unhealthy,  or  the  walls  of  the  bladder 
are  thin  and  atonied,  lest  a  drop  or  two  escape  through  the  punc- 
ture and  set  up  septic  inflammation  and  suppuration,  which  may 
be  followed  by  extravasation  of  urine. 

5.  Retention  from  hysteria  should  be  combated  by  such  moral 
and  physical  treatment  as  is  applicable  to  that  disease.  A  cathe- 
ter should  not  be  passed  if  it  can  be  possibly  avoided.  A  hot 
sponge  applied  to  the  pubes  is  often  successful. 

6.  Retention  f7-om  paralysis  or  atony  of  the  bladder,  from  abscess 
or  tumor  of  the  urethra  or  bladder,  from  impacted  calculus,  and 
from  ligature  of  the  pelvis,  is  discussed  under  the  heads  of  Paraly- 
sis of  the  Bladder,  Impacted  Calculus,  etc. 

Puncture  of  the  bladder  above  the  pubes  (Fig.  284,  b). — 
Make  a  small  incision  through  the  skin  immediately  above  the 
pubes,  having  first  ascertained  by  percussion  that  the  bladder  has 
risen  well  out  of  the  pelvis,  and  thrust  Cock's  curved  trocar  and 
cannula  downwards  and  backwards  into  the  bladder.  Withdraw 
the  trocar,  secure  the  cannula  in  situ,  and  pass  through  it  a  soft 
catheter  connected  with  a  long  rubber  tube  to  carry  away  the 
urine.  In  a  few  days,  when  the  parts  are  consolidated,  the  can- 
nula should  be  changed.  When  the  bladder  is  distended,  a  gtgved 
inch  rises  above  the  pubes  uncovered  by  peritoneum,  but  when 
contracted  and  hypertrophied  it  may  rise  but  little,  if  at  all. 
Under  these  latter  circumstances  the  trocar  and  cannula  must  be 
passed  close  to  the  pubes,  for  fear  of  wounding  the  peritoneum. 

Aspiration  is  performed  in  a  similar  way,  except  that  the  aspi- 
rating needle  or  trocar  is  thrust  in  without  any  preliminary  inci- 
sion of  the  skin.  If  a  small  aspirating  needle  or  cannula  is  used 
there  is  no  danger  of  extravasation,  as  on  its  vvithdrawal  the 
puncture  in  the  bladder  is  closed  by  the  contraction  of  the  mus- 
cular fibres  ;  and  even  should  a  drop  or  two  of  urine  escape  no 
harm  will  ensue,  provided  the  urine  is  healthy.  It  is  a  most 
useful  emergency  operation,  and,  if  necessary,  may  be  repeated 
on  several  successive  occasions. 

PuNcruRE  of  the  bladder  THROUGH  THE  RECTUM. — Place  the 
patient  in  the  lithotomy  position.  Pass  the  left  forefinger  into 
the  rectum,  and  place  its  tip  just  beyond  the  back  of  the  prostate. 
Take  Cock's  long  curved  trocar  and  cannula,  with  the  point  of 


72$ 


DISEASES    OF    REGIONS. 


the  trocar  slightly  withdrawn  within  the  cannula.  Introduce  it 
through  the  anus,  and  guide  it  by  the  finger  in  the  rectum  to  a 
spot  immediately  behind  the  prostate  exactly  in  the  middle  line. 
Press  the  cannula  firmly  on  the  fluctuating  trigone  of  the  bladder, 
and  plunge  the  trocar  boldly  into  the  bladder,  in  a  direction  up- 
wards and  forwards  towards  the  umbilicus.  Withdraw  the  trocar 
and  secure  the  cannula  /;/  situ  with  suitable  tapes.  Do  not  plug 
the  cannula,  but  fix  an  india-rubber  tube  on  its  end  and  convey 
this  to  a  vessel  beneath  the  bed. 

DISEASES  OF  THE  GENITAL  ORGANS. 
DISEASES    OF    THE    PENIS. 

Paraphlmosis  is  the  strangulation  of  the  glans  penis  by  a  tight 
prepuce-  which  has  been  drawn  back  over  it,  and  cannot  be  re- 
placed. Thus,  it  is  not  infrequently  met  with  in  boys,  from  the 
accidental  uncovering  of  the  glans  and  neglect  to  draw  the  pre- 
puce forward  again.  In  adults  it  is  generally  due  to  swelling, 
caused  by  gonorrhoea  or  venereal  sores,  but  it  may  occasionally 
occur  during  coitus.  It  is  attended  with  great  oedema  of  the 
glans  and  prepuce,  and  if  not  soon  reduced  may  lead  to  ulcera- 

FlG.  354. 


Mclliod  of  dividing  the  stricture  in  parnphimosis.     (Tiryant's  SurRcry.) 

tion  at  the  line  of  constriction,  or  even  to  sloughing  of  the  penis. 
7'reat7ncni. — Seize  the  penis  between  the  first  and  second  fingers 
of  each  hand,  press  the  blood  and  oedema  out  of  the  glans  with 
the  thumbs,  and  at  the  same  time  push  the  glails  backwards  and 
try  to'  draw  the  prepuce  forwards  over  it.  If  this  fails,  divide 
with  a  knife  (Fig.  354)  the  constricting  band,  which  lies  just  be- 


DISEASES    OF    THE    GENITAL    ORGANS. 


729 


hind  the  fold  of  oedematous  prepuce  at  the  bottom  of  the  furrow 
on  the  dorsum  of  the  penis. 

Phimosis  is  a  condition  in  which  the  prepuce  is  elongated,  and 
its  orifice  contracted,  so  that  it  cannot  be  drawn  back  over  the 
glans.  It  may  occur  as  a  congenital  affection  ;  or  it  may  be 
acquired,  and  is  then  usually  due  to  the  cicatricial  contraction  of 
the  orifice  following  syphilitic  ulceration  or  repeated  attacks  of 
gonorrhoea.  The  orifice  when  very  small  may  cause  difficulty  of 
micturition  or  even  retention  of  urine  ;  whilst  the  straining  to  pass 
water  may  induce  prolapse  of  the  rectum,  hernia,  irritation  of  the 
bladder,  and  symptoms  of  stone,  and  if  not  reheved  may  produce 
the  harmful  effects  on  the  urinary  organs  described  under  stricture  ; 
or  the  deposit  of  the  urinary  salts  beneath  the  prepuce  may  lead 
to  the  formation  of  preputial  calculi.  The  inability  to  uncover  the 
glans  may  cause  pain  and  difficulty  in  coitus,  and  by  preserving  a 
mucous  membrane-like  character  to  the  glans  predispose  to  vene- 
real disease  ;  whilst  the  secretion  which  collects  beneath  the 
prepuce  may,  in  conse- 
quence of  the  irritation  it  Fig.  353. 
is  apt  to  set  up,  induce 
priapism,  habits  of  mas- 
turbation, inflammation 
sometimes  simulating 
gonorrhoea,  adhesion  of 
the  glans  to  the  prepuce, 
or  even  as  age  advances 
the  formation  of  an  epi- 
thelioma. The  treatment 
may  be  considered  under 
the  head  of  i,  circujn- 
cision  ;  2,  slitting  the  pre- 
puce; and  3,  dilatation  of 
the  preputial  orifice. 

1.  Circumcision. — Lay  hold  of  the  prepuce  transversely  with 
a  pair  of  polypus  forceps,  on  a  level  with  the  corona  (Fig.  355)  ; 
let  the  glans  slip  back,  close  the  forceps,  and  shave  off  the  prepuce 
in  front  of  them  with  a  clean  sweep  of  the  knife,  llemove  the 
forceps,  slit  up  the  mucous  lining  of  the  prepuce  in  the  middle 
Hne  quite  back  to  the  corona,  break  down  any  adhesions  between 
the  prepuce  and  glans,  wash  away  the  secretion,  twist  or  tie  any 
spurting  vessels,  and  stitch  the  flaps  of  mucous  membrane  to  the 
skin  with  interrupted  horse-hair  or  catgut  sutures.  Dress  with 
boracic  lint  or  iodoform  gauze. 

2.  Slitting  the  prepuce  may  be  done  with  scissors,  or  with  a 
curved  bistoury  guided  by  a  director,  introduced   between    the 


Seizing  the  prepuce  preparatory  to  the  operation  of 
circumcision.     (Bryant's  Surgerj-.) 


73©  DISE.\SES   OF   REGIONS. 

glans  and  prepuce.  In  either  case  the  mucous  membrane  should 
be  united  to  the  skin-flaps  by  fine  sutures  after  twisting  and  tying 
any  bleeding  vessels.  Care  should  be  taken  not  to  pass  the  di- 
rector into  the  meatus,  and  to  ensure  that  the  mucous  membrane 
is  slit  quite  back  to  the  corona. 

3.  Dilatation  of  the  prepuce  may  be  accomplished  in  slight  cases 
by  a  daily  endeavor  to  draw  back  the  contracted  prepuce  over  the 
glans.  It  may  also  be  done  by  the  preputial  dilator,  or  by  forcible 
separation  of  the  blades  of  the  dressing  forceps,  though  such 
means  are  not  often  successful. 

Primary  venereal  sores  or  chancres. — Two  chief  varieties  of 
venereal  sore  or  chancre  occur,  the  syphilitic  or  infecting,  and  the 
local  contagious  or  non-infecting.  Either  of  these  may  be  accom- 
panied by  sloughing  or  phagedaena,  and  is  then  spoken  of  as 
sloughing  and  phagedaenic  sore  or  chancre. 

1.  The  primary  syphilitic  chancre  has  already  been  described 
in  the  section  on  syphilis  (p.  66). 

2.  The  local  contagious  or  non-infecting  sore,  the  soft  chancre  or 
chancroid,  as  it  is  sometimes  called  to  distinguish  it  from  the  hard 
or  svphilitic  chancre,  is  a  specific  form  of  ulceration  probably  de- 
pending upon  a  distinct  variety  of  micro-organism.  Though  this 
ulcer,  like  the  syphilitic,  may  occur  on  any  part  of  the  body  that 
is  inoculated  with  the  specific  virus,  it  is  so  much  more  frequently 
met  with  on  the  genitals  that  it  is  described  with  diseases  of  these 
organs.     It  is  not  followed  by  constitutional  symptoms. 

Signs. — Non- infecting  or  soft  chancres  are  most  frequent  at  the 
junction  of  the  glans  and  prepuce,  where  they  often  take  the  form 
of  a  ring  of  small  ulcers  around  the  corona  glandis.  More  rarely 
they  are  met  with  on  the  muco-cutaneous  or  cutaneous  surface  of 
the  organ.  They  usually  begin  as  a  small  pustule  or  slight  excori- 
ation within  a  few  days  of  inoculation,  and  when  fully  established, 
appear  as  small  oval  ulcers,  with  sharply-cut  edges  and  a  slightly 
depressed  base  covered  with  a  greyish  slough,  and  surrounded  by 
a  red  areola  of  inflammation.  When  irritated,  as  by  the  rubbing 
of  the  clothes,  or  the  retention  of  the  secretion  beneath  a  long 
prepuce,  they  may  become  indurated  ;  but  the  induration  has  not 
the  sharply-defined  character  of  the  syphilitic  sore.  The  inguinal 
glands  become  enlarged  {bubo),  and  matted  together  into  a  single 
mass,  often  of  considerable  size,  and  have  a  marked  tendency  to 
suppurate.  The  pus  taken  from  them  apparently  contains  the 
same  micro-organism  as  that  of  the  sore,  since  when  inoculated 
on  the  same  or  another  person  a  similar  sore  is  produced. 

Diagnosis. — The  main  differences  between  a  non-infecting  or 
soft  sore,  and  an  infecting  or  hard,  are  the  following  : — The  soft 
sore  is  generally  unattended   with   induration ;  in  the  hard  the 


EPITHELIOMA.  73 1 

induration  is  generally  well  marked  ;  the  soft  occurs  within  a  few 
days  of  inoculation,  the  hard  not  till  after  three  to  five  weeks  ;  in 
the  soft  the  secretion  is  abundant  and  purulent,  in  the  hard 
scanty,  and  often  consists  of  little  more  than  epithelial  debris ; 
the  soft  can  be  reinoculated  on  the  same  patient,  and  hence  is 
frequently  multiple  ;  the  hard  cannot  be  reinoculated  on  the  same 
patient,  and  hence  is  single  unless,  as  very  rarely  happens,  the 
patient  is  inoculated  in  two  places  at  the  same  time.  The  bubo 
following  the  soft  sore  is  single,  soft,  and  very  liable  to  suppurate ; 
that  following  the  hard  sore  is  multiple,  hard,  and  shotty,  and 
very  rarely  suppurates.  A  patient,  however,  may  be  inoculated 
with  syphilis  at  the  same  time  that  he  receives  a  soft  sore. 
Hence,  when  the  incubative  period  of  syphihs  has  passed,  the 
soft  sore  may  take  on  the  characters  of  the  hard  sore.  Till  this 
period  is  over,  therefore,  a  cautious  prognosis  as  to  ihe  probable 
occurrence  of  secondary  symptoms  should  be  given.  It  is  con- 
sequently not  uncommon  to  find  a  patient  with  a  chancre  which 
presents  characters  both  of  the  hard  and  soft  sore. 

Treatment. — Local  treatment  only  is  necessary,  and  consists  in 
scrupulous  cleanliness,  protection  of  the  sore  from  irritation,  and 
the  appHcation  of  black-wash,  zinc  lotion,  or  iodoform.  Should 
the  glands  become  inflamed,  rest  in  the  recumbent  posture  is 
essential.  If  the  suppuration  threatens,  hot  poultices  must  be 
applied  and  a  free  incision  in  a  vertical  direction  made  as  soon 
as  pus  has  formed.  Should  any  intractable  sinuses,  as  frequently 
happens,  be  left  after  the  bubo  has  suppurated,  they  should  be 
laid  freely  open,  and  allowed  to  granulate  from  the  bottom. 

3.  The  sloi/ghi?}g  sore  is  due  to  want  of  cleanliness  or  the  re- 
tention of  irritating  discharges  by  a  long  foreskin,  and  generally 
occurs  in  weakly  or  debilitated  subjects.  The  sore,  which  is  cov- 
ered with  a  yellow  slough,  and  is  surrounded  by  an  angry  areola 
of  inflammation,  spreads  rapidly,  and  is  attended  with  consider- 
able swelling  and  oedema  of  the  penis.  The  general  appearances 
of  the  ulcer  and  its  appropriate  treatment  have  already  been  given 
in  the  section  on  Ulcers  (p.  48). 

4.  The  phagedcEiiic  sore — Phagedrena  may  attack  both  the  hard 
and  soft  sore,  bist  is  said  by  Mr.  Hutchinson  to  be  a  more  fre- 
quent complication  of  the  former  than  of  the  latter.  Like  the 
sloughing  sore,  it  may  be  due  to  want  of  cleanliness  and  neglect, 
or  to  the  irritation  of  the  discharges  retained  by  a  long  foreskin. 
It  seldom,  however,  occurs  to  any  serious  extent,  except  in  those 
whose  constitutions  are  broken  down  by  want  of  food,  abuse  of 
alcohol,  debauchery,  or  exhausting  disease.  For  a  description 
of  the  characters  and  treatment  of  this  ulcer  see  p.  48. 

Epithelioma  of  the  penis  generally  begins  as  a  warty  growth  or 


732  DISEASES   OF   REGIONS. 

as  an  ulcer  on  the  glans  or  inner  surface  of  the  prepuce.  Old 
age  is  looked  upon  as  the  chief  predisposing,  and  the  irritation 
of  retained  secretion  under  a  long  prepuce  as  the  common  ex- 
citing cause.  The  indurated,  sinuous  and  everted  edges  of  the 
ulcer,  the  warty  base,  sanious  and  foul  discharge,  rapid  growth, 
advanced  age  of  the  patient,  and  later,  the  involvement  of  the 
inguinal  glands,  will  generally  serve  to  distinguish  it  from  warts 
or  venereal  ulcers,  for  which  it  may  be  mistaken.  If  allowed  to 
nm  its  course  the  whole  penis  becomes  infiltrated  with  the  growth  ; 
the  lumbar,  as  well  as  the  inguinal  glands,  become  involved ; 
sloughing  and  ulceration  ensue,  and  the  patient  generally  dies  of 
exhaustion  or  hsemorrhage.  The  internal  organs  are  not  usually 
affected.  Treatment. — If  seen  early,  the  growth  alone  may  be 
removed.  As  a  rule,  however,  the  penis  should  be  amputated  in 
front  of  the  scrotum  unless  the  glands  are  much  involved  or  the 
disease  extends  backwards  beyond  this  point.  In  such  a  case  the 
scrotum  may,  under  certain  conditions,  be  %\)\\X.,  the  whole  penis, 
with  the  crura,  removed,  and  the  urethra  stitched  to  the  perin- 
eum. The  inguinal  glands,  if  not  too  extensively  diseased,  should 
be  also  removed. 

Amputation  of  the  penis  is  often  performed  by  one  sweep  of 
the  knife  ;  when  thus  done  the  urethra  is  liable  to  retract  and 
cause  subsequent  trouble  in  micturition.  It  is  best  therefore  to 
divide  the  corpus  spongiosum  about  half  an  inch  further  forward 
than  the  corpora  cavernosa,  and  then  split  the  urethra  and  secure 
it  by  four  sutures  to  the  skin.  The  skin  should  be  drawn  well 
forward  before  it  is  divided,  as  otherwise  it  is  apt  to  obscure  the 
more  retractable  stump,  and  render  the  securing  of  the  arteries 
difficult.  Too  much  skin,  moreover,  is  liable  to  obstruct  the 
orifice  of  the  urethra.  Haemorrhage  during  the  operation  should 
be  restrained  by  Clover's  clamp  or  by  the  fingers  of  an  assistant. 
The  two  dorsal  arteries  and  the  arteries  of  the  corpora  cavernosa 
and  of  the  septum  usually  require  ligature.  Amputation  by  the 
galvanic  ecraseur  is  strongly  advised  by  some,  but  is  open  to  the 
objection  that  it  may  be  followed  by  secondary  haemorrhage  on 
the  separation  of  the  sloughs. 

DISEASES   OF   THE   SCROIUM,  SPERMA'IIC   CORD,  AND   TESTICF.E. 

Epithelioma  of  the  scrotum,  often  called  sweep's  cancer,  from 
the  frequency  with  which  it  occurs  in  chimney-sweepers,  owing  to 
the  irritation  of  the  soot,  generally  begins  as  a  dark  wart  or  tuber- 
cle which  ultimately  ulcerates,  producing  a  sore  with  hard  sinuous 
everted  edges,  and  an  irregular  warty  tuberous  base.  At  times  it 
begins  as  a  chronic  eczema.     The  irritant  would  appear  to  be  not 


HYDROCELE.  733 

merely  the  carbon  of  the  soot,  but  one  or  more  of  the  products  of 
the  destructive  distillation  of  coal,  as  the  cancer  does  not  occur 
from  soot  produced  by  the  burning  of  wood,  and  is  found  amongst 
workers  in  coal-tar  and  its  products.  The  inguinal  glands  become 
involved,  and  occasionally  the  testicle,  but  the  disease  does  not,  as 
a  rule,  affect  internal  organs.  Death  is  commonly  due  to  the 
exhaustion  produced  by  the  ulceration  in  the  inguinal  glands,  or 
haemorrhage  from  the  opening  of  a  large  blood-vessel  in  the  groin. 
T}-eatmeut. — Free  and  early  excision  with  the  knife,  and  removal 
of  the  inguinal  glands  if  enlarged  and  hard.  If  the  testicle  is  in- 
volved it  should  be  excised  at  the  same  time.  The  skin  of  the 
part  is  very  lax,  and  although  the  testicle  may  be  denuded  it  rap- 
idly becomes  covered  in. 

QEdema  of  the  scrotum,  owing  to  the  laxity  of  the  tissues,  is 
common.  It  may  occur  in  kidney  and  heart  disease  as  part  of  the 
general  dropsy,  or  it  may  be  caused  by  inflammation  of  the  neigh- 
boring parts,  as  the  testicle.  It  is  also  met  with  in  extravasation 
of  urine,  and  may  occur  after  an  operation  for  hernia,  varicocele, 
etc. 

ERYS1PEL.AS  OF  THE  scROTUiM  may  be  the  result  of  slight  injuries, 
abrasions,  etc.,  or  may  occur  idiopathically.  It  is  attended  with 
great  swelling,  redness  and  oedema,  and  is  very  liable  to  terminate 
in  extensive  sloughing  and  gangrene.  The  same  general  and  local 
treatment  should  be  adopted  as  described  under  Erysipelas,  with 
free  and  early  incisions  should  suppuration  threaten. 

Eczema  and  prurigo  of  the  scrotum  require  no  special  mention. 

Elephantiasis  scroti  is  an  enormously  hypertrophied  condition 
of  the  skin  and  connective  tissue  of  the  scrotum,  and  probably 
depends  (like  a  somewhat  similar  condition  known  as  lymph- 
scrotinn,  in  v/hich  a  milky  fluid  exudes  from  the  skin)  on  the 
presence  in  the  blood  of  the  filaria  sanguinis  hominis.  The  dis- 
ease is  common  in  the  East,  but  is  seldom  met  with  in  this  coun- 
try, and  then  hardly  ever  except  in  those  who  have  lived  in  the 
East.  The  penis  is  sometimes  affected  in  a  similar  manner. 
Treatment. — The  hypertrophied  mass  may  be  dissected  off  the 
testicle  and  penis,  after  elevating  it  for  some  hours  before  the 
operation,  in  order  to  drain  it  as  much  as  possible  of  blood.  The 
base  of  the  mass  during  the  operation  should  be  constricted  by 
an  elastic  band. 

Hydrocele  is  a  collection  of  serous  fluid  in  connection  with 
the  testicle  or  spermatic  cord.  There  are  several  varieties  of 
hydrocele.  Thus,  the  fluid  may  be  contained  in  the  tunica  vagi- 
nalis {commoJi  or  vaginal  hydrocele^;  and  this  is  further  spoken 
of  as  congenital  when  the  tunica  vaginalis  communicates,  through 
the  non- obliteration  of  its  funicular  process,  with  the  general  peri- 


734  DISEASES   OF    REGIONS. 

toneal  cavity,  or  as  acute  when  associated  with  acute  inflammation 
of  the  testicle  or  epididymis.  Again,  the  fluid  may  be  contained 
in  a  cyst  in  connection  with  the  testicle  or  epididymis  {encysted 
hydrocele  of  the  testicle  or  epididymis^,  or  contained  in  a  cyst  formed 
in  connection  with  the  spermatic  cord  {encysted  hydrocele  of  the 
spermatic  cord).  The  condition  described  by  Pott  and  Scarpa  as 
diffuse  hydrocele  of  the  spermatic  cord  appears  to  be  a  general 
dropsy  of  the  loose  connective  tissue  of  the  cord,  and  is  so  rare 
that  it  may  be  dismissed  without  further  comment. 

Common  or  vaginal  hydrocele  is  a  collection  of  serous  fluid  in 
the  cavity  of  the  tunica  vaginalis. 

Causes. — Infancy,  middle  age,  heredity,  gout,  and  malaria  are 
said  to  predispose  to  it ;  whilst  slight  injuries,  repeated  strains, 
the  presence  of  loose  bodies  in  the  tunica  vaginalis,  and  certain 
chronic  diseases  of  the  testicle,  are  sometimes  exciting  causes. 
Often,  however,  no  apparently  efficient  cause  whatever  can  be 
discovered. 

Pathology. — By  some  it  is  looked  upon  as  a  passive  dropsy,  due 
to  a  loss  of  balance  between  the  secreting  and  absorbing  power 
of  the  tunica  vaginalis  ;  by  others  it  is  believed  to  be  due  to  chronic 
inflammation.  The  fluid  is  of  a  pale  straw  color,  with  a  specific 
gravity  of  1020  to  1030,  and  contains  a  large  quantity  of  albumen. 
The  dilated  tunica  vaginalis  is  usually  thin,  but  in  long  standing 
cases  it  is  occasionally  greatly  thickened,  and  may  be  of  cartila- 
ginous consistency.  The  coverings  are  the  same  as  those  of  the 
testicle,  viz.,  skin,  superficial  fascia,  dartos,  and  intercolumnar, 
cremasteric  and  infundibuliform  fasciae. 

Symptoms. — Ordinary  hydrocele  forms  a  smooth,  tense,  elastic 
or  fluctuating  swelling  in  the  scrotum,  of  a  pyriform,  globular  or 
oval  shape,  and  is  frequently  slightly  constricted  at  its  middle  or 
at  its  lower  or  upper  ])art.  The  chief  diagnostic  sign  is  its  trans- 
lucency.  If  the  walls  are  very  thick  it  may  appear  opaque  when 
examined  for  translucency  in  the  usual  way  by  the  light  of  a  can- 
dle, but  I  have  never  met  with  a  hydrocele,  however  thick  its 
walls,  which  was  not  found  translucent  when  a  powerful  light,  as 
that  of  an  opthalmoscopic  lamp,  was  used.  The  cord  is  free,  and 
there  is  no  impulse  on  coughing,  signs  which  serve  to  distinguish 
it  from  a  hernia.  When  the  hydrocele  extends  up  the  funicular 
portion  of  the  tunica  vaginalis  into  the  inguinal  canal  there  may, 
however,  be  a  transmitted  impulse  from  the  abdominal  wall ;  it 
might  then  be  mistaken  fcjr  an  irreducible  hernia.  The  dullness 
on  ]jercussion,  the  history  that  it  began  at  the  bottom  of  the  scro- 
tum, and  the  translucency,  if  the  light  be  powerful  enough,  will 
distinguish  it.  'l"he  testicle  is  situated  behind  and  near  its  lower 
part,  save  in  exceptional  cases,  where  adhesions  have  been  con- 


COMMON   OR   VAGINAL   HYDROCELE.  735 

tracted  to  the  anterior  wall,  or  the  testicle  has  descended  retro- 
verted. 

The  t7'eatment  may  be  palliative  or  radical.  Palliaiive  treat- 
ment consists  in  tapping  the  hydrocele  with  a  trocar  and  cannula, 
and  repeating  the  operation  from  time  to  time  as  required.  Be- 
fore tapping  a  hydrocele  the  situation  of  the  testicle  should  be 
made  out,  lest  it  be  injured  by  the  trocar.  This  can  usually  be 
done  by  marking  the  opaque  spot  whilst  examining  for  translu- 
cency,  and  by  the  patient's  sensation  on  handling  it.  If  the  sac 
is  not  very  tense  the  testicle  can  be  felt.  Choose  a  spot  for 
puncture  near  the  bottom  of  the  swelling,  free  from  scrotal  veins, 
which  can  readily  be  seen  through  the  skin,  and  having  made  out 
the  situation  of  the  testicle,  grasp  the  tumor  from  behind  with  the 
palm  of  the  hand  so  as  to  make  it  tense,  and  plunge  the  trocar 
and  cannula,  held  as  in  Fig.  356,  sharply  into  the  sac  to  ensure 

Fig.  356. 


Tapping  a  hydrocele.     (Bryant's  Surgery.) 

perforating  the  wall.  The  trocar  should  be  directed  at  first  back- 
wards, and  then  immediately  turned  upwards  to  avoid  wounding 
the  testicle.  Having  withdrawn  the  fluid,  remove  the  cannula, 
and  apply  a  small  pad  of  lint  or  strapping. 

The  radical  cure  is  commonly  effected  by  injecting  tincture  of 
iodine  into  the  sac  through  the  cannula  after  having  withdrawn  the 
fluid.  The  quantity  injected  is  usually  about  two  drachms.  If 
ten  drops  of  a  5%  solution  of  cocaine  are  injected  befoie  the 
iodine  no  pain  generally  is  felt.  The  iodine  sets  up  some  slight 
amount  of  inflammation,  and  generally  cures  by  restoring  the 
balance  between  the  secreting  and  absorbing  power  of  the  tunica 
vaginalis,  or  occasionally  by  causing  adhesions  between  the  two 
layers  of  the  tunica  vaginalis.  Should  the  injection  fail,  it  may 
be  repeated  ;  or  the  tunica  vaginalis  may  be  laid  open,  a  portion 
cut  away,  and  the  remainder  united  by  suture  and  drained.     But 


736  DISEASES   OF   REGIONS. 

even  this  treatment  cannot  always  be  depended  on  for  curing  the 
hydrocele.  The  only  absolutely  certain  method  is  to  lay  open 
the  sac  and  allow  it  to  granulate  up  from  the  bottom. 

The  hydroceles  so  frequently  seen  in  young  children  generally 
undergo  a  spontaneous  cure,  and  nothing  beyond  a  discutient 
lotion  is  usually  necessary.  Should  the  hydrocele  prove  intract- 
able, however,  it  may  be  punctured  with  a  fine  trocar  and  can- 
nula, and,  if  necessary,  afterwards  injected  with  a  weak  solution 
of  iodine. 

Congenital  hydrocele  is  a  collection  of  fluid  in  the  sac  of  the 
tunica  vaginalis,  the  funicular  process  of  which  through  an  arrest 
of  development  has  remained  unobliterated.  The  fluid,  there- 
fore, unless  the  aperture  of  communication  is  very  small,  can  be 
readily  pressed  back  into  the  abdominal  cavity,  and  an  expansile 
impulse  is  given  to  it  on  coughing  or  crying.  In  this  respect  it 
resembles  a  hernia;  but  its  translucency  and  the  fact  that  the 
fluid  goes  back  slowly  and  without  the  sudden  slip  or  gurgle,  as  is 
the  case  in  a  hernia,  should  serve  to  distinguish  it.  It  should  not 
be  forgotten  that  a  piece  of  omentum  or  intestine  may  descend 
into  the  sac  of  the  hydrocele.  At  times,  the  aperture  of  com- 
munication between  the  funicular  process  and  the  general  peri- 
toneal cavity  is  closed,  and  though  the  hydrocele  still  extends 
more  or  less  up  the  inguinal  canal,  the  fluid  cannot  be  pressed 
back  into  the  abdominal  cavity.  To  this  condition  the  name  ot 
infantile  hydrocele  has  been  given. 

Treatment. — k  truss  should  be  api)lied  over  the  inguinal  canal  to 
cause  obliteration  of  the  funicular  portion  of  the  tunica  vaginalis, 
and  to  prevent  the  descent  of  a  hernia,  and  subsequently  the 
hydrocele  may  be  treated  in  the  ordinary  way.  As  a  rule,  how- 
ever, when  the  obliteration  of  the  funicular  portion  has  been 
accomplished,  the  hydrocele  undergoes  a  spontaneous  cure. 

Encysted  hydrocele  of  the  tesmcle. — This  term  is  applied 
to  a  cyst  or  cysts  formed  in  connection  with  the  testicle  or  epi- 
didymis, but  having  no  communication  with  the  cavity  of  the 
tunica  vaginalis.  Cysts  in  connection  with  the  testicle  itself  are 
very  rare  and  require  no  further  description  here.  Encysted 
hydroceles  of  the  epididymis,  however,  though  still  rare,  are  more 
often  met  with,  and  may  be  divided  into  (i)  the  subserous  cysts, 
which  are  of  no  clinical  importance,  and  (2)  the  spermatic  cysts. 
The  latter  are  thin-walled,  membraneous  cysts  lined  with  tesselated 
epithelium,  and  containing  a  watery,  slightly  opalescent  or  milky 
fluid,  in  which  there  is  often  an  abundance  of  spermatozoa.  The 
presence  of  the  spermatozoa  may  be  due  to  the  ru])ture  into  the 
cyst  of  one  of  the  seminal  ducts  ;  or  to  the  cyst  being  developed 
in  connection  with  a  seminal  duct.     The  origin  of  these  cysts  is 


VARICOCELE.  737 

doubtful.  They  are  generally  believed,  however,  to  be  developed 
from  some  of  the  foetal  remains  (Wolffian  body,  Miillerian  duct, 
etc.)  so  abundant  in  the  situation  of  the  epididymis. 

Signs. — They  appear  as  tense,  fluctuating,  translucent,  movable, 
globular,  smooth  or  lobulated  swellings,  without  impulse  on  cough, 
and  situated  immediately  above  or  behind  the  testicle.  The  cord 
is  generally  free.  They  are  often  combined  with  an  ordinary 
hydrocele. 

The  treatment  is  like  that  of  ordinary  hydrocele. 

Encysted  hydrocele  of  the  spermatic  cord  is  a  collection  of 
serous  fluid  in  an  unobliterated  portion  of  the  funicular  process  of 
the  tunica  vaginahs.  The  fluid  is  similar  to  that  of  an  ordinary 
hydrocele.  The  coverings  of  the  cyst  are  those  of  the  funicular 
process,  viz.,  the  skin,  and  the  superficial,  intercolumnar,  cremas- 
teric, and  infundibuliform  fasciae ;  the  vas  with  the  arteries  and 
veins  are  behind  it. 

Signs. — An  encysted  hydrocele  of  the  cord  appears  as  a  well- 
defined,  tense,  oval  or  globular,  fluctuating,  freely  movable  swell- 
ing in  the  course  of  the  spermatic  cord.  It  is  unconnected  with 
the  testicle  below,  and  cannot  be  reduced  into  the  abdomen 
above,  although  it  may  be  pushed  back  some  distance  up  the  in- 
guinal canal.  It  is  translucent,  and  gives  no  impulse  on  coughing. 
But  when  high  up  in  the  inguinal  canal,  it  may  be  difficult  to 
distinguish  from  a  small  irreducible  hernia,  as  an  impulse  is 
communicated  to  it  from  the  abdominal  walls,  and  it  may  be  im- 
practicable to  detect  its  translucency.  A  cautious  puncture  with 
a  grooved  needle  may  then  be  necessary  to  diagnose  it. 

Treatment. — Painting  with  tincture  of  iodine  may  first  be  tried. 
This  faihng,  the  cyst  should  be  punctured  with  a  small  trocar  and 
cannula.  Should  it  refill,  it  may  be  injected  with  iodine,  like  an 
ordinary  hydrocele,  or  it  may  be  laid  open  by  an  antiseptic  inci- 
sion. But  before  undertaking  its  radical  cure,  it  must  be  ascer- 
tained that  there  is  no  communication  with  the  peritoneum. 
This  may  usually  be  done  by  noting  that  no  decrease  in  size  takes 
place  on  applying  steady  pressure  for  some  little  time. 

Varicocele  is  a  dilated  and  varicose  condition  of  the  spermatic 
plexus  of  veins  (Fig.  357). 

The  causes  of  varicocele  are  not  really  known.  It  has  been 
attributed  to  an  extra  lax  state  of  the  parts,  induced  by  debility 
and  general  \vant  of  tone ;  congestion  from  too  early  or  continual 
excitement  of  the  sexual  organs  ;  occupations  involving  long  stand- 
ing ;  and  to  certain  anatomical  peculiarities  (all  of  which,  how- 
ever, are  present  in  every  healthy  male),  such  as  the  great  length 
of  the  spermatic  veins,  the  dependent  position  of  the  -testicle,  the 
plexiform  arrangement  of  the  veins  in  the  scrotum,  etc.  But  it 
31* 


738 


DISEASES   OF    REGIONS. 


Varicocele.  (St. 
Bartholomew's 
Hospital  Mu- 
seum.) 


often  occurs  in  men  in  good  health,  and  in  whom  the  parts  are 
not  lax.  The  reasons  given  for  its  much  greater  frequency  on  the 
left  than  on  the  right  side  are — i,  that  the  left  vein  is  longer  than 
the  right ;  2,  that  an  obstacle  is  offered  to  the  outlet 
of  the  left  vein  by  its  opening  at  right  angles  into 
the  renal  vein  ;  3,  that  the  blood  pressure  is  less  in 
the  vena  cava  than  in  the  renal  vein ;  4,  that  the 
left  vein  is  crossed  by  the  sigmoid  flexure,  and  is 
hence  liable  to  be  pressed  upon  by  fjecal  accumu- 
lations. Mr.  W.  G.  Spencer,  who  has  recently 
worked  at  this  subject,  believes  that  the  presence  of 
the  large  veins  is  due  to  a  congenital  variation  from 
the  normal  process  of  development,  whereby  many 
of  the  veins  of  the  Wolffian  body  (from  which  the 
spermatic  veins  are  formed)  remain  unobliterated, 
and  capable  of  being  dilated  by  anything  obstruct- 
ing the  return  of  venous  blood  from  the  testicle. 
More  of  these  veins,  he  says,  are  normally  obliterated 
on  the  right  than  on  the  left  side. 

Symptoms  and  diagnosis. — There  may  be  merely 
a  sense  of  weight  and  fulness  in  the  scrotum,  or  dragging  or  even 
severe  pain,  worse  after  the  day's  work  but  relieved  by  recum- 
bency. The  symptoms,  however,  are  often  more  mental  than 
physical,  the  patient  fearing  impotence  or  sterility,  and  sometimes 
becoming  hypochondriacal  in  consequence.  The  varicose  veins, 
which  may  sometimes  be  seen  through  the  skin  of  the  scrotum, 
form  a  soft,  irregular,  opaque,  knotted,  pyriform  mass,  in  which 
there  is  a  distinct  expansile  thrill  or  impulse  on  cough.  The 
swelling  is  confined  to  the  scrotum,  and  although  it  may  be  re- 
duced on  the  patient's  lying  down,  it  does  not  go  back  with  a 
gurgle  or  slip  like  a  hernia,  and  gradually  returns  when  the  patient 
rises,  notwithstanding  that  the  finger  is  placed  over  the  external 
abdominal  ring.  The  testicle,  though  perhaps,  as  a  rule,  a  little 
smaller  than  natural,  is  seldom  much  atrophied.  The  treat mcnt 
may  be  either  palliative  or  radical. 

The  palliative  treatment  consists  in  cold  sponging,  the  use  of 
shower-baths,  healthy  exercise,  regulation  of  the  bowels,  and  the 
administration  when  indicated  of  ferruginous  tonics  ;  whilst  the 
mental  anxiety  of  the  patient  should  be  relieved  by  the  assurance 
that  atrophy  or  impotence  need  not  be  feared.  Locally,  a  sus- 
pensory bandage  should  be  worn,  or  the  veins  braced  up  by 
drawing  the  lower  part  of  the  scrotum  through  a  IVormald's  ring. 
The  radical  treatment  should  only  be  undertaken  (i)  when  the 
varicocele  is  large  or  causes  much  pain  ;  (2)  when  it  acts  as  a  bar 
to  entering  the  public  services;  or  (3)  when  it  appears  to  be  in- 


HEMATOCELE    OR    COiAfMON    HEMATOCELE.  739 

ducing  atrophy  of  the  testicle.  Whether  it  should  or  should  not 
be  undertaken  for  the  cure  of  mental  distress,  must  be  left  to  the 
judgment  of  the  Surgeon  in  each  individual  case.  The  operations 
for  the  radical  cure,  which  have  for  their  object  the  obliteration 
of  the  enlarged  veins,  are  many.  Here  only  is  described  the 
method  by  subcutaneous  ligature  and  division.  Separate  the  vas, 
which  can  always  be  felt  as  a  rounded  cord  from  the  veins ;  pass 
with  a  nsevus-needle  a  thread  of  catgut  or  kangaroo-tail  tendon 
between  the  veins  and  the  vas,  and  then  back  again  between  the 
veins  and  the  skin,  and  tie  the  veins,  allowing  the  knot  to  slip 
through  the  puncture  in  the  skin.  Repeat  the  procedure  three 
quarters  of  an  inch  above,  and  place  the  scrotum  in  an  antiseptic 
dressing.  The  spermatic  arteries  escape  injury  as  they  slip  away 
with  the  vas,  to  which  they  are  attached. 

Other  methods  consist  in  the  subcutaneous  division  of  the  veins 
with  the  galvano-cautery  wire  ;  excision  of  the  veins  ;  compression 
of  the  veins  by  hare-lip  pins  and  figure-of-eight  sutures  ;  division 
of  the  veins  with  the  elastic  ligature,  etc.  The  method  described 
above  can  be  recommended  as  safe,  painless,  efficient,  easy  of 
performance,  and  as  necessitating  the  minimum  amount  of  rest 
subsequent  to  its  performance. 

Tumors  of  the  spermatic  cord,  though  occasionally  met  with, 
are  too  rare  to  require  any  description  in  a  work  of  this  character. 

Torsion  of  the  spermatic  cord,  /.  e.,  a  twisting  of  the  cord  so 
that  the  epididymis  is  felt  in  front  instead  of  behind  the  body  of 
the  testis,  is  occasionally  met  with  either  in  a  testis  to  all  exter- 
nal appearance  previously  normal,  or  in  a  testis  retained  in  the 
inguinal  canal.  The  twisting  has  been  attributed  to  spasm  of  the 
cremaster.     If  unrelieved  the  testicle  will  atrophy  or  necrose. 

Symptoms. — The  torsion  is  attended  by  a  tender  and  painful 
swelling  in  the  groin  or  scrotum,  dull  on  percussion,  irreducible, 
and  without  impulse  on  cough,  the  symptoms  generally  coming 
on  suddenly  after  great  strain  or  exertion.  Vomiting  is  nearly 
always  present,  and  there  may  be  constipation.  Thus  when  the 
testis  is  retained  a  strangulated  hernia  is  very  closely  simulated. 

Treatment. — When  seen  early  the  cord  may  be  readily  un- 
twisted if  the  testis  is  in  the  scrotum,  the  symptoms  at  once  dis- 
appearing as  in  Nash's  case.  If  the  testis  is  in  the  groin  or 
inguinal  canal,  it  should  be  removed  and  the  canal  and  ring 
closed  by  sutures. 

H.-EMATOCELE  or  COMMON  HEMATOCELE  is  an  cffusion  of  blood 
into  the  cavity  of  the  tunica  vaginalis.  Blood  may  also  be  effused 
into  an  encysted  hydrocele  of  the  testis,  epididymis  or  cord,  into 
the  substance  of  the  testicle  itself,  or  into  the  tissue  of  the  scro- 
tum ;  and  to  such  the  terms  hsematocele  of  the  testis,  hagmatocele 


740  DISEASES   OF   REGIONS. 

of  the  cord,  etc.,  have   been  applied.     All  of  these  conditions, 
however,  are  too  rare  to  admit  of  any  description  here. 

Cause. — An  ordinary  h^ematocele  may  be  due  to  a  blow  on  the 
testicle,  or  a  strain  in  lifting  heavy  weights,  or  a  like  injury  to  a 
hydrocele  ;  to  puncture  of  the  testicle  or  a  blood-vessel  in  tapping 

a  hydrocele ;  or  to  the  giving 
Fig.  358.  way  of  a  weakened  or  varicose 

vessel  in  consequence  of  the 
alteration  in  tension  on  removal 
of  the  hydrocele-fluid  by  tap- 
ping. At  times,  however,  it 
may  occur  spontaneously,  and 
is  then  probably  due  to  some 
atheromatous  or  other  change 
in  the  vessels,  or  chronic  in- 
flammation of  the  tunica  vagi- 
nalis. 

Pathology. — The  effused  blood 
may  be  absorbed,  or  it  may  clot 

Haematocele.     (St.   Bartholomew's   HosDital  ,    ,         ,  .,      ,  ^1  n 

Museum.)  *         ^ud  be  deposited  on  the  walls 

of  the  sac,  giving  the  haemato- 
cele on  section  the  appearance  of  an  aneurysm  (Fig.  3s8)  ;  or 
the  central  portions  of  the  clot  may  break  down  into  a  chocolate- 
colored  fluid,  which  under  the  microscope  is  seen  to  consist  of 
disintegrating  blood-corpuscles  and  hDem.atin  and  cholesterin 
crystals.  At  times  suppuration  may  take  place,  the  fluid  in  the 
sac  then  consisting  of  a  mixture  of  broken-down  blood  and  pus. 
Calcification  of  the  walls  in  old-standing  cases  may  occur. 

Signs  and  diagnosis. — Hematocele  comes  on  suddenly,  appear- 
ing as  a  smooth,  tense  or  semi-fluctuating,  oval  or  globular,  non- 
translucent  swelling  in  the  scrotum.  At  first  there  may  be  con- 
siderable pain  in  the  testicle  and  ecchymosis  of  the  scrotum  ;  but 
later,  neither  as  a  rule  will  be  present.  Testicular  sensation  is 
generally  discovered  behind  the  swelling.  The  freedom  of  the 
cord  and  absence  of  impulse  on  coughing  should  at  once  serve  to 
diagnose  it  from  a  hernia,  and  its  non-translucency  from  a  hydro- 
cele. But  from  malignant  and  other  growths  it  is  often  difficult 
to  distinguish  it ;  and  indeed  in  some  cases  it  is  only  after  punc- 
ture with  a  grooved  needle,  or  even  after  an  exploratory  incision, 
that  this  can  be  done.  The  history  of  its  sudden  onset,  its  shape, 
the  absence  of  the  varying  consistency  noted  in  malignant  dis- 
ease, the  non-involvement  of  the  glands  or  of  the  cord,  and  the 
presence  of  testicular  sensation  posteriorly,  should  help  in  the 
diagnosis.  On  puncture  a  chocolate-colored  fluid  escapes  in  the 
one  case ;  arterial  blood,  or  nothing  at  all,  in  the  other. 


ACUTE    INFLAJNI.MATION    OF    THE    TESTICLE.  74 1 

Treatment. — When  the  hasmatocele  is  recent,  rest  in  bed,  the 
application  of  cold  or  of  evaporating  lotions,  and  the  elevation  of 
the  part  on  a  pillow,  may  lead  to  the  absorption  of  the  blood.  If 
this  fails,  the  blood  may  be  withdrawn  with  a  trocar  and  cannula. 
When  such  is  done,  however,  the  sac  in  my  experience  generally 
refills,  and  I  believe  time  is  gained  in  the  end  by  at  once  making 
a  free  incision  into  the  sac,  turning  out  the  clots,  securing  any 
bleeding  vessel  that  may  be  seen,  and  allowing  the  wound  to 
heal  by  granulations.  In  long-standing  cases,  and  especially 
when  the  walls  are  much  thickened,  this  treatment  is  clearly  in- 
dicated ;  but  if,  on  laying  the  sac  open,  the  walls  are  found  of 
cartilaginous  consistency,  perhaps  calcified,  and  the  patient  is  old 
or  broken  down  in  constitution,  excision  of  the  testicle  is  then 
called  for,  as  otherwise  long-continued  suppuration,  which  may 
terminate  in  exhaustion  and  death,  may  ensue.  Where  suppura- 
tion has  occurred,  a  free  incision  should,  under  any  circum- 
stances, at  once  be  made. 

Acute  inflaminiation  of  the  testicle  is  generally  spoken  of  as 
orchitis  or  as  epididymitis,  according  as  the  body  or  the  epididy- 
mis is  primarily  or  chiefly  affected. 

Causes. — Gonorrhoea  is  the  most  frequent  cause  ;  but  injury  of 
the  testicle,  or  irritation  of  the  prostatic  urethra,  as  from  the 
tying  in  of  a  catheter,  or  from  the  impaction  of  a  calculus  or 
fragment  of  a  calculus,  are  not  uncommon  causes.  Orchitis 
sometimes  occurs  during  an  attack  of  mumps,  and  is  then  said  to 
be  due  to  metastasis.  It  has  also  been  attributed  to  the  use  of 
strong  injections  for  the  cure  of  gonorrhoea.  How  inflammation 
of  the  testicle  is  induced  by  the  irritation  of  the  urethra  is  a  dis- 
puted question.  It  is  variously  taught,  however,  that  it  is  due  to 
— I,  inflammation  spreading  along  the  vas ;  2,  reflex  irritation ; 
and  3,  metastasis. 

Pathology. — The  walls  of  the  tubules  and  the  intertubular  con 
nective  tissue  become  infiltrated  with  inflammatory  products,  and 
the  tubules  filled  with  desquamated  epithelium.  Resolution 
usually  occurs,  leaving  the  testicle  little  or  not  at  all  impaired 
either  in  structure  or  function.  Suppuration,  however,  is  occa- 
sionally induced  ;  and  when  the  epididymis  is  chiefly  involved, 
the  inflammatory  material,  in  place  of  being  absorbed,  may  be 
converted  into  fibrous  tissue,  which,  subsequently  contracting, 
may  cause  obstruction  of  the  tubules  of  the  epididymis.  Such 
may  be  known  to  have  occurred  by  the  presence  of  a  small  hard 
lump  in  the  region  of  the  globus  minor  or  major.  An  effusion  of 
fluid  into  the  tunica  vaginalis  {acute  hydrocele^  is  very  common, 
but  more  so  in  epididymitis  than  in  orchitis,  because  the  visceral 
layer  of  the  tunica  vaginalis  is  in  contact  with  the  inflamed  tissue 


742  DISEASES   OF   REGIONS. 

in  the  former  case,  but  is  separated  from  it  by  the  thick  tunica 
albuginea  in  the  latter. 

Si!^/2s. — In  a  well-marked  case  there  is  intense  pain  in  the 
testicle,  with  a  dragging  or  aching  pain  in  the  groin  and  along 
the  course  of  the  cord.  The  testicle  is  swollen,  and  exquisitely 
tender  on  handling;  the  cord  feels  slightly  thickened  ;  and  the 
skin  of  the  scrotum  is  oedematous  and  of  a  dusky-red  color. 
When  the  inflammation  falls  on  the  epididymis,  the  pain  and 
swelling  will  be  chiefly  confined  to  the  lower  and  back  part  of  the 
testicle — the  region  of  the  epididymis — and  fluid  will  often  be 
detected  in  the  tunica  vaginalis.  The  discharge,  if  the  inflamma- 
tion of  the  testicle  occurs  during  an  attack  of  gonorrhoea,  gener- 
ally ceases  or  becomes  less  when  the  inflammation  is  at  its  height. 
The  local  signs  are  often  accompanied  by  sharp  febrile  disturb- 
ance, raised  temperature,  furred  tongue,  nausea  or  even  vomiting, 
and  constipation. 

Treatment. — When  the  attack  is  acute,  rest  in  bed  with  the 
testicle  supported  on  a  pillow  is  desirable.  Hot  fomentations, 
and  in  the  intervals  hot  linseed-meal  poultices,  applied  to  the 
testicle  and  groin,  give  the  most  reUef.  Internally  a  brisk  purge 
should  be  given  at  the  onset,  followed  by  saline  laxatives  and 
small  doses  of  antimony.  If  the  pain  is  very  severe,  opium  may 
be  given ;  or  a  vein  of  the  scrotum  opened  ;  or  the  tunica  vagi- 
nalis or  testicle  punctured  to  reUeve  tension,  either  with  a  needle 
in  several  places'  or  with  a  tenotomy  knife.  If  suppuration 
occurs,  a  free  incision  should  be  made  to  let  out  the  pus.  In 
subacute  attacks,  where  the  patient  is  unable  to  leave  his  work,  a 
suspensory  bandage  should  be  worn. 

Chronic  inflammation  of  the  testicle  may  be  a  sequel  to  the 
acute  disease  ;  or  it  may  begin  as  a  chronic  or  subacute  affection, 
and  like  the  acute  form  may  involve  either  the  body  of  the  testi- 
cle or  the  epididymis,  or  both.  The  two  chief  causes  of  chronic 
inflammation  are  undoubtedly  syphilis  and  tubercle  ;  but  it  may 
occur  quite  independently  of  either  of  these  affections,  and  should 
then,  for  the  sake  of  distinction,  be  called  simple  chronic  orchitis 
or  epididymitis.  The  syphilitic  and  tubercular  {oxxs\%  are  described 
separately  under  those  heads. 

Si^ns. — The  testicle  appears  enlarged,  smooth,  laterally  com- 
pressed, egg-shaped,  hard,  heavy,  and  painful  on  pressure  ;  the 
testicular  sensation  is  not  lost ;  the  vas  is  but  slightly  thickened  ; 
the  skin  is  non-adherent,  and  the  epididymis  (except  when  the 
disease  is  limited  to  that  part)  is  not  distinguishable  from  the 
body  of  the  organ.  In  chronic  epididymitis  an  indurated,  painful, 
and  tender  lump  is  felt  in  the  situation  of  the  globus  minor  or 
major. 


TUBERCULAR   DISEASE    OF   THE    TESTIS.  743 

Treatment. — Mercury  or  iodide  of  potassium  should  be  given 
internally,  and  strapping  applied  to  the  enlarged  organ  when  the 
body  is  chiefly  affected.  In  chronic  epididymitis,  in  addition  to 
internal  remedies,  inunction  with  mercurial  ointment  may  be  of 
service. 

Tubercular  disease  of   the   testis,  also  known  as  strumous 
orchitis,  or  strumous  sarcocele,  is  variously  believed  to  depend  upon 
the  presence  of  the  tubercle  bacillus, 
or  upon  a  chronic  inflammation  in  Fig.  359. 

a  strumous  subject,  and  to  begin 
either  as  a  tubercular  affection  in 
the  intertubular  connective  tissue, 
or  as  a  catarrhal  inflammation  in 
the  interior  of  the  tubules. 

Pathology.  —  Opportunities  for 
examining  the  testicle  in  the  early 
stages  of  the  disease  are  not  com- 
mon. Hence,  the  uncertainty  as 
to  the  origin  and  exact  nature  of 
the  inflammation.  Typical  nodules 
of  tubercle,  however,  have  been 
found,  and  tubercle  bacilli  have 
been  demonstrated  either  in  sec- 
tions of  the  organ  or,  when  few  in     ^.^^^^^^,^  ^^  ^^^  ^^^^i^,^    ^s^  b^^^^^,. 

number,     after      cultivation.  The  omew's  Hospital  Museum.) 

disease    generally    begins   in   the 

epididymis,  and  thence  may  spread  to  the  body  of  the  organ. 
It  may  also  extend  up  the  vas  to  the  vesiculae  seminales  and  pros- 
tate, and  thence  to  the  bladder,  and  even  to  the  ureters  and  kid- 
neys. In  some  cases  the  testicle  appears  to  be  the  starting  point 
of  a  general  tuberculosis ;  in  others,  merely  to  be  involved  in  com- 
mon with  other  organs  in  the  general  disease.  In  many  in- 
stances, however,  the  disease  may  remain  localized  to  the  testicle, 
and  no  other  manifestation  of  tubercle  occur  in  the  body.  The 
inflammatory  products  infiltrating  the  epididymis  and  testicle, 
have  a  great  tendency  to  undergo  caseation,  forming  the  yellow 
masses  of  cheesy-hke   material    so  characteristic  of   the  disease 

(Fig.  359)- 

Sip;ns. — The  disease  usually  begins  very  insidiously  and  with 
little  pain.  The  epididymis,  especially  the  head,  and  later  the 
body  of  the  testicle,  are  found  enlarged.  The  testicle  is  usually 
but  sightly  tender  on  handHng,  and  the  testicular  sensation  is  not 
lost ;  a  hydrocele  may  be  present,  or  part  of  the  tunica  vaginalis 
may  be  obliterated.  Subsequently  the  cord,  especially  the  vas, 
becomes  thickened  and  the  skin  adherent;  whilst  still  later,  the 


744  DISEASES   OF    REGIONS. 

skin  may  give  way  and  a  fungus  composed  of  the  infiltrated  tubules 
protrude,  or  a  discharging  sinus  be  produced.  The  vesiculse 
seminales  or  prostate  may  now  be  felt  enlarged  on  examining  by 
the  rectum,  and  bladder  or  urinary  troubles  may  set  in;  whilst 
symptoms  of  tubercle  in  the  lung,  larynx  or  other  organs  may 
supervene  and  the  patient  succumb  to  tubercular  disease.  At 
other  times  no  constitutional  signs  manifest  themselves,  and  the 
patient  may  comj^letely  recover. 

Diagjwsis. — From  syphilitic  orchitis  it  may  generally  be  dis- 
tinguished by  the  enlargement  of  the  epididymis,  thickening  of 
the  cord,  adhesion  of  the  skin,  enlargement  of  the  vesicul?e  semi- 
nales, and  concomitant  signs  of  tubercle  elsewhere. 

Treatment. —  In  the  early  stages,  before  the  vas  or  vesiculse 
seminales  have  become  involved,  some  Surgeons  advise  the  removal 
of  the  organ,  for  the  purpose  of  preventing,  if  possible,  general 
dissemination  of  the  disease,  and  where  both  testicles  are  affected, 
even  the  removal  of  both.  Others,  however,  rely  on  constitutional 
treatment,  and  only  advise  the  removal  of  the  testicle  should  it 
become  destroyed  by  the  disease.  If  the  vesiculse  seminales  are 
found  affected  in  the  early  stages,  or  signs  of  tubercle  are  dis- 
covered in  other  parts,  the  testicle  should  of  course  on  no  account 
be  excised.  The  constituiiojial  treatment  is  that  already  described 
under  Tubercle  (p.  63).  The  local  treatment  con?>\si?,  in  suspen- 
sion of  the  organ,  avoidance  of  horse  or  other  violent  exercise, 
and  recumbency  during  an  exacerbation  of  the  inflammation. 
Should  the  tubercle  soften  and  suppuration  occur,  the  abscess 
must  be  opened  and  the  wound  dressed  with  iodoform  or  other 
antiseptic.  If  intractable  sinuses  remain,  they  should  be  scraped 
with  a  Volkmann's  spoon.  If  a  fungus  forms  it  will  frequently 
recede  under  rest  in  bed,  cleanliness,  and  the  application  of  a 
stimulating  ointment  or  of  iodoform.  Should  the  testicle  become 
completely  disorganized  it  had  better  be  excised. 

Syphilitic  disease  of  the  testicle  occurs  during  the  late 
secondary  and  the  tertiary  stages  of  syphilis.  Pathology. — 'I'he 
lesion  in  the  earlier  stages  of  syphilis  usually  takes  the  form  of  a 
small- cell-infiltration  of  the  intertubular  connective  tissue  ;  in  the 
later  stages,  of  distinct  gummatous  masses,  resembling  gummata 
in  other  situations.  The  body  of  the  testicle  alone  is  usually 
affected,  and  though,  in  some  instances,  syphilitic  epididymitis  is 
met  with,  the  cord  and  epididymis  generally  escape.  In  the 
secondary  stage  both  testicles  may  be  imiilicated,  either  simul- 
taneously, or,  as  more  often  happens,  one  after  the  other,  the 
disease  here,  as  in  other  secondary  affections,  manifesting  its 
tendency  to  be  symmetrical.  Under  appropriate  treatment  the 
small-cell-infiltration  may  be  completely  absorbed,  leaving  the 


SYPHILITIC   DISEASE   OF   THE   TESTICLE. 


745 


Syphilitic  testicle.     Gummatous  variety.     (St. 
Barthlomew's  Hospital  Museum.) 


testicle  apparently  little,  if  at  all  affected  ;  or  it  may  undergo 
fibroid  changes,  and  the  subsequent  shrinking  of  the  fibrous  tissue 
produce  more  or  less  atrophy  of  the  organ.  But  it  seldom  breaks 
down  and  suppurates,  as  the  gummatous  form  in  patients  with 
undermined  constitutions  is  apt  to  do.  In  the  tertiary  affection 
one  testicle  only  is,  as  a  rule,  involved,  the  asymmetrical  character 
of  tertiary  syphilis  being  thus 

borne  out.      The  gummatous  ^''^-  3^°- 

masses  may  clear  up  under 
treatment,  but  where  the  con- 
stitution is  impaired  they  are 
liable  to  break  down  and  sup- 
purate. The  typical  appear- 
ance of  a  gummatous  testicle 
on  section  is  seen  in  Fig.  360. 
The  organ  is  occupied  by  large 
yellowish-white  nodules  of  a 
tough,  fibrous,  non-vascular 
material ;  some  of  the  gummata 
are  distinct;  the  remainder 
have  coalesced  into  a  mass 
which  occupies  the  anterior 
part  of  the  organ,  A  loose 
fibroid  tissue,  which  is  very  vascular  and  of  a  pink  color  in  the 
original  specimen,  surrounds  and  separates  the  nodules. 

S/'g/is. — Syphilitic  disease  is  very  insidious  and  painless  in  its 
onset,  the  testicle  often  attaining  some  size  before  the  patient's 
attention  is  directed  to  it.  The  testicle  is  enlarged,  very  hard, 
not  tender  on  handling,  and,  as  a  rule,  absolutely  painless ;  the 
testicular  sensation  is  completely  lost ;  the  skin  is  not  involved, 
appears  but  natural,  and  is  freely  movable  over  the  swelling. 
The  signs,  however,  vary  somewhat  according  to  the  stage  of 
syphilis  at  which  the  testicle  is  affected.  Thus,  in  the  secondary 
stages,  the  testicle  is  smooth,  oval,  and  often  laterally  compressed  ; 
in  the  tertiary,  nodular  and  irregular,  and  the  tunica  vaginalis  fre- 
quently contains  fluid  (vai^/zui/  hydrocek).  In  the  secondary, 
usually  both  testicles  are  affected ;  in  the  tertiary  often  only  one. 
In  the  tertiary,  moreover,  the  gummata,  in  neglected  cases,  or 
where  the  constitution  is  undermined,  may  break  down,  the  skin 
become  involved  in  the  inflammation  and  give  way,  and  a  sore 
having  the  characters  of  a  tertiary  syphilitic  ulcer  result.  More 
rarely  a  fungus  may  protrude.  The  characters  of  the  secondary 
and  tertiary  disease,  however,  often  merge  into  each  other.  A 
syphilitic  testicle  may  have  to  be  diagnosed  from  simple  orchitis 
and   from   tubercular  disease.     The    freedom   of  the    cord  and 


746 


DISEASES   OF   REGIONS. 


epididymis,  the  absence  of  all  pain  and  tenderness  on  handling, 
the  loss  of  testicular  sensation,  the  hardness  of  the  organ,  the  non- 
imphcation  of  the  skin,  the  presence  of  a  vaginal  hydrocele,  the 
history  of  syphilis,  the  fact  that  the  patient  has  not  had  gonor- 
rhoea or  a  previous  attack  of  acute  orchitis,  nor  received  an  in- 
jury to  the  testicle,  and  the  absence  of  signs  of  tubercle  in  other 
organs,  point  to  the  disease  being  of  a  syphilitic  origin.  It  must 
not  be  forgotten,  however,  that  syphilis  may  occur  in  a  strumous 
subject ;  and  that  the  characters  of  the  two  affections  may  then  be 
more  or  less  combined. 

Tieafment. — The  earlier  the  testicle  is  affected  in  the  course  of 
constitutional  syphilis,  the  more  marked  will  be  the  effect  of  mer- 
cury ;  the  later,  of  iodide  of  potassium.  Often  the  best  results 
are  obtained  from  the  two  drugs  combined.  Locally,  the  testicle 
may  be  merely  suspended ;  or  it  may  be  strapped  in  the  earlier 
stages  with  advantage.  Any  fluid  in  the  tunica  vaginalis  will  com- 
monly be  absorbed  during  the  treatment,  though  sometimes  tap- 
ping may  be  required.  Should  the  skin  give  way,  and  an  ulcer 
be  produced,  it  should  be  treated  like  other  syphilitic  ulcers.  In 
rare  instances,  where  the  testicle  is  totally  disorganized,  extirpa- 
tion may  become  necessary. 

Enchondromata  or  cartilaginous  tumors  of  the  testicle  are 


Fig.  361. 


Fig.  362. 


^^^'''^''^t^^?ss^:0''^'K;,^„^  ::,,,,  .y^^^' 


Knchondroma  ol    the  testicle.     (St.  Bartholomew's  Hos- 
pital Museum.) 


Soft  carcinoma  of  the  testicle. 
I  St.  liartholomew's  Hospital 
Museum.) 


very  rare.  A  beautiful  example,  however,  is  shown  in  the  ac- 
companying illustration  (Fig.  361).  They  may  be  known  by 
their  extreme  hardness.  Removal  of  the  testicle  is  the  proper 
treatment. 

Malignant  disease  of  the  ticsticle  generally  occurs   in  the 


MALIGNANT    DISEASE    OF    THE    TESTICLE.  747 

form  of  a  round- celled  sarcoma,  more  rarely  in  the  form  of  soft 
carcinoma  ;  but  v,'ithout  a  microscopical  examination,  the  two 
diseases,  even  on  section,  are  often  quite  indistinguishable. 
Sarcoma  begins  in  the  intertubular  connective  tissue,  and  most 
frequently  occurs  in  early  life  ;  carcinoma  in  the  tubules,  as  a  pro- 
Hferation  of  the  epithelial  lining,  and  is  most  common  after  the 
period  of  middle  age.  In  both,  the  body  of  the  organ  is  pri- 
marily affected,  and  all  distinction  between  it  and  the  epididymis  is 
soon  lost.  Some  effusion  into  the  tunica  vaginalis  may  at  first 
occur ;  the  two  surfaces,  however,  rapidly  become  adherent,  the 
skin  is  implicated,  and  a  fungating  mass  protrudes  externally. 
The  lumbar  glands  are  generally  affected,  the  inguinal  only  be- 
coming involved  after  the  skin  has  been  reached.  In  a  typical 
case  (Fig.  362)  the  growth  appears,  on  section,  like  a  mass  of 
brain-matter  blotched  in  places  with  blood  :  whilst  fibrous  bands, 
the  remains  of  the  trabeculae  testis,  are  generally  seen  traversing 
the  growth.  Masses  of  cartilage  are  often  found  in  the  sarco- 
mata, and  cysts,  sometimes  containing  intracystic  growths,  are  not 
uncommon  {cystic  sarcoma).  The  disease  formerly  described  as 
cystic  sarcocele  would  generally  appear  to  be  of  such  a  nature. 

Signs. — The  swelling  is  at  first  generally  uniform,  smooth,  elas- 
tic or  tense,  and  hard,  and  no  distinction  between  the  body  and 
the  epididymis  can  be  made  out ;  but  later  the  cord  becomes 
thickened  and  the  lumbar  glands  enlarged,  and  the  tumor  may 
feel  hard  in  one  place  and  soft  in  another.  Ultimately  the  skin 
becomes  adherent,  gives  way,  and  a  fungating  mass,  covered  with 
a  sanious  discharge,  protrudes. 

Diagnosis. — The  rapid  growth,  large  size,  and  more  or  less 
globular  shape  of  the  tumor ;  the  lancinating  pain  ;  the  implica- 
tion of  the  skin  and  lumbar  glands  ;  the  enlargement  of  the  scrotal 
veins ;  the  protrusion  of  a  bleeding  fungus  :  and,  later,  the  con- 
stitutional cachexia,  will  indicate  malignancy.  In  the  early  stages, 
however,  a  puncti^re  or  even  an  exploratory  incision  may  be  nec- 
essary to  distinguish  it  from  chronic  orchitis,  haematocele,  and 
syphilitic^-orchitis.  Thus,  in  malignant  disease,  arterial  blood  will 
generally  flow  ;  in  hsematocele  a  chocolate-colored  fluid  contain- 
ing hsematin  crystals  and  broken-down  blood  corpuscles  will 
escape ;  and  in  chronic  orchitis,  whether  simple,  syphilitic,  or 
tubercular,  ncjthing  beyond  perhaps  a  drop  or  two  of  blood  will 
be  withdrawn  by  the  cannula.  At  times  a  piece  of  the  growth 
may  come  away  in  the  end  of  the  cannula,  and  a  microscopical 
examination  of  this  will  further  aid  in  the  diagnosis. 

Treatment — Unless  ihe  glands  are  much  affected,  the  cord  is 
thickened,  and  great  emaciation  or  cachexia  is  present,  with  signs 
of  the  disease  in  the  internal  organs,  excision  of  the  testicle  should 


748  DISEASES   OF   REGIONS. 

be  performed.  When  this  appears  undesirable  from  the  above- 
mentioned  reasons,  all  that  can  be  done  is  to  give  opium  to  relieve 
pain  and  tonics  to  keep  up  the  general  health,  and  to  apply  some 
disinfecting  lotion  to  remove  the  fcetor  attending  the  fungating 
mass.  After  removal  of  the  testicle  an  early  recurrence  of  the 
disease  in  the  lymphatic  glands  or  in  the  internal  organs  is  only 
too  probable. 

Excision  of  the  testicle. — The  parts  having  been  shaved, 
make  an  incision  over  the  growth  from  the  external  abdominal 
ring  to  the  bottom  of  the  scrotum.  Free  the  cord  from  its  con- 
nections, and  having  clamped  and  divided  it,  enucleate  the  testicle 
with  a  few  touches  of  the  knife,  taking  care  not  to  cut  through  the 
scrotal  septum,  and  so  remove  the  other  testicle  at  the  same  time, 
a  danger  best  avoided  by  giving  the  sound  testicle  into  the  charge 
of  an  assistant.  Next  tie  the  spermatic  artery  in  the  stump  of  the 
cord,  and  the  cremasteric  and  deferent'.al  arteries,  if  seen ;  and 
having  secured  the  cord  by  a  Spencer  Wells'  forceps,  in  order  to 
prevent  it  slipping  into  the  inguinal  canal,  loosen  the  clamp,  and 
tie  any  other  vessel  that  may  then  bleed  before  finally  releasing  it. 

Atrophy  of  the  testicle  may  be  simply  the  result  of  old  age,  or 
it  may  be  due  to — 1,  inflammation,  especially  that  occurring  dur- 
ing an  attack  of  mumps  ;  2,  interference  with  its  blood  supply,  as 
from  the  compression  of  the  spermatic  artery  by  a  new  growth  or 
aneurysm  ;  3,  obstruction  to  the  venous  return,  as  in  varicocele  ; 
4,  direct  pressure  on  the  organ,  as  by  an  old  htcmatoceie,  or  by 
the  abdominal  muscles,  or  by  a  truss  when  the  testicle  is  retained 
in  the  inguinal  canal. 

Neuralgia  of  the  testicle  is  occasionally  met  with,  but  pain  in 
the  testicle  should  not  be  pronounced  neuralgic  till  the  various 
diseases  of  the  kidney,  rectum,  bladder  and  prostate,  which  may 
give  rise  to  reflected  pain  in  the  testicle,  have  been  excluded. 
When  no  cause  for  the  pain  can  be  discovered,  the  ordinary  neu- 
ralgic remedies  should  be  given,  although  the  prospect  of  success 
from  their  use  is  not  great. 

Retained  tf.siicle. — Non-descent  of  the  testicle  is  said  to  be 
due  to — I,  the  formation  of  adhesions  in  any  part  of  its  course 
into  the  scrotum  ;  2,  disjiroportion  between  the  size  of  the  testicle 
and  the  abdominal  rings  ;  3,  paralysis  of  the  gubernaculum  testis; 
4,  too  short  a  condition  of  the  spermatic  cord  ;  and  5,  malforma- 
tion of  testicle.  Thus  the  union  between  the  vas  deferens  and  the 
testicle,  /.  c,  the  union  of  the  Wolffian  duct  and  the  portion  of 
blastema  from  which  the  body  of  the  testicle  is  dcveloi)ed,  may  not 
occur,  and  the  vas  descends  alone.  The  testicle  may  be  retained 
in  one  of  three  situations,  viz.,  i,  in  the  abdominal  cavity  ;  2,  in 
the  inguinal  canal ;  and  3,  just  outside  the  external  abdominal 


DISEASES    OF    THE    VULVA.  749 

ring.     In  the  two  latter  situations  it  is  often  associated  with  a 
congenital  hernia. 

Treatme7it. — In  \\\&  first  situation  nothing  can  be  done.  In  the 
third  the  testicle  should  be  coaxed  into  the  scrotum  by  gende  and 
oft-repeated  manipulations,  and  a  truss  with  a  <-shaped  pad,  the 
arms  of  the  <  embracing  the  testis,  applied  over  the  inguinal 
canal  should  there  be  signs  of  a  hernia.  If  this  truss  does  not 
keep  up  the  hernia,  the  testis  had  better  be  removed  and  the  canal 
and  ring  closed  by  suture.  In  some  instances  the  cord  may  be 
elongated  sufficiently  to  allow  the  testis  to  be  placed  in  the  scro- 
tum by  detaching  the  globus  minor  from  the  body  of  the  organ, 
and  thus  turning  the  testis  upside  down.  The  sac  of  the  hernia 
may  then  be  removed  and  the  canal  and  ring  closed.  When  the 
testicle  is  retained  in  the  inguinal  canal,  time  should  be  given  it 
to  descend,  and  a  truss  applied  if  possible  over  the  internal  ring. 
Should  it  not  descend  as  the  child  grows  older,  the  question  of  its 
removal  must  be  raised,  as  in  this  situation  atrophy  of  the  organ 
is  nearly  sure  to  ensue,  and  it  is  liable  to  be  frequently  attacked 
by  inflammation,  and  to  be  affected  by  malignant  disease.  More- 
over, it  exposes  the  patient  to  the  risks  of  hernia.  In  some  cases, 
however,  it  may  be  returned  into  the  abdomen,  and  kept  there  by 
a  truss,  or  by  closing  the  canal. 


SURGICAL  DISEASES  OF  THE  FEMALE  GENITAL  ORGANS. 
DISEASES    OF   THE   VULVA. 

Adhesion  of  the  labia  majora  sometimes  occurs  as  a  congeni- 
tal affection.  The  labia  should  be  separated  by  forcibly  drawing 
them  asunder,  with  the  assistance,  if  necessary,  of  a  probe,  and 
a  piece  of  iodoform  gauze  placed  between  them  to  prevent  re- 
adhesion.  If  neglected,  it  may  be  a  source  of  inconvenience  at 
puberty.  The  parts  are  then  more  firmly  adherent,  and  may 
require  division  by  the  knife. 

Vulvitis,  or  inflammation  of  the  vulva,  is  in  adults  most  usually 
the  result  of  gonorrhoea,  but  occurs  in  young  children  from  other 
causes,  such  as  cold,  injury,  the  irritation  of  thread-worms,  etc. 
Sometimes  the  sebaceous  glands  and  hair-follicles  of  the  labia  are 
chiefly  affected,  the  parts  then  appearing  dotted  over  with  small 
red  pimples,  and  later,  if  suppuration  occurs,  with  small  pustules. 
There  is  usually  much  redness  and  oedema,  and  an  offensive  dis- 
charge. It  is  of  some  importance  to  recognize  the  fact  that  the 
disease  may  occur  in  children  from  simple  causes,  as  amongst  the 
poor,  mothers  are  apt  to  think  their  child  has  been  tampered  with. 
Treatment. — In  addition  to  the  removal  of  the  cause,  cleanliness, 


75°  DISEASES   OF   REGIONS. 

rest,  attention  to  the  general  health,  and  the  use  of  a  mild  astrin- 
gent lotion,  is  all  that  is  usually  required. 

Abscess  occasional))'  follows  inflammation  of  the  vulva.  It  is 
often  due  to  the  extension  of  inflammation  (generally  gonorrhoeal) 
to  Bartholin's  gland,  or  to  suppuration  in  a  labial  cyst.  A  free  and 
early  incision  should  be  made  to  prevent  burrowing  of  pus,  which 
is  otherwise  apt  to  occur,  leading  to  the  formation  of  obstinate 
fistulcC.     Should  these  form,  they  should  be  laid  freely  open. 

Cysts  in  the  labium  are  generally  due  to  the  obstruction  of  a 
raucous  follicle  or  the  duct  of  Bartholin's  gland,  as  the  result  of 
irritation.  Dermoid  and  sebaceous  cysts  are  more  rarely  met 
with.  The  mucous  cysts  generally  contain  a  glairy  fluid,  and  as 
their  walls  are  thin,  appear  as  semi-translucent,  oval,  elastic  swell- 
ings. They  occasionally  suppurate.  Excision  of  a  portion  of  the 
wall,  and  cauterization,  plugging,  or  scraping  away  the  lining 
membrane  to  ensure  healing  from  ihe  bottom,  is  all  that  is  usually 
necessary. 

Tumors. — Fibrous  tumors  are  occasionally  met  with  in  the 
labium.  They  are  usually  of  the  soft  variety,  and  often  contain 
myxomatous  elements.  They  are  frequendy  allowed  to  attain  a 
large  size.  Removal  is  the  only  treatment.  Fatty  tumors  and 
ncevi  are  also  met  with  ;  sarcomata  but  rarely. 

Fpithelioma  is  not  uncommon,  and  may  generally  be  distin- 
guished from  venereal  warts  and  syphilitic,  tubercular  or  lupoid 
ulceration  by  the  surrounding  induration,  the  sinuous  and  everted 
edges  of  the  ulcer,  the  history  of  the  case,  the  age  of  the  patient, 
and  the  early  enlargement  of  the  inguinal  gl  mds.  Early  and  wide 
removal  of  the  growth,  together  with  any  inguinal  glands  that  may 
be  felt  enlarged,  holds  out  the  only  prospect  of  success  ;  but  when 
the  growth  has  attained  any  size,  a  rapid  recurrence  is  but  too 
frequent. 

Condylomata  and  venereal  waris  are  very  common  in  this 
situation.  They  require  no  special  description,  and  should  be 
treated  as  described  under  Venereal  Diseases  in  the  Male. 

Pruritus  may  depend  on  various  causes.  These  should  be 
sought,  and,  if  possible,  removed,  the  irritation  being  allayed  in 
the  meantime  by  such  remedies  as  are  mentioned  under  Pruritus 
^/;/(p.  653). 

Elephantiasis  of  the  lap.ium  is  rare.  Like  the  similar  condi- 
tion of  the  scrotum,  it  may  attain  a  large  size.  It  may  be  re- 
moved by  the  knife,  or  better,  as  the  haemorrhage  is  free,  by  the 
galvano -cautery. 

Noma  is  an  infective  inflammation  of  the  vulva,  attended  by 
phagedaenic  ulceration,  and  is  not  infrequently  met  with  in  the 
ill-fed,  weakly  children  of  the  poor,  esi)ecially  after  the  exanthe- 


VESICO-VAGINAL   FISTULA.  75  1 

mata.  Like  cancrum  oris,  it  probably  depends  upon  the  presence 
of  a  specific  micro-organism.  It  begins  as  a  dusky-red,  indurated 
patch  on  one  labium,  with  much  swelling  and  oedema,  and  spreads 
rapidly,  the  central  parts  often  becoming  gangrenous.  It  is  at- 
tended with  severe  constitutional  disturbance,  which  soon  assumes 
the  typhoid  type,  and  death  from  exhaustion  or  septiccsmia  fre- 
quently ensues.  The  treatment  should  be  energetic.  The  affected 
part  should  be  scraped  with  a  Volkraann's  spoon,  or  destroyed  by 
fuming  nitric  acid  or  the  cautery,  and  an  antiseptic  dressing  ap- 
plied ;  whilst  fluid  nourishment,  stimulants,  and  iron  should  be 
freely  given,  and  opium  cautiously  administered  in  doses  suitable 
to  the  age  of  the  child.  In  milder  cases  the  apphcation  of  boro- 
glyceride  may  suffice.  In  very  severe  cases,  the  continuous  warm 
bath  has  been  found  of  great  service. 

DISEASES    OF   THE   VAGINA. 

Acute  vaginitis  is  generally  due  to  gonorrhoea,  but  may  occur 
as  the  result  of  the  use  of  strong  injections,  the  introduction  of 
foreign  bodies,  cold,  and  the  exanthemata.  It  is  attended  with 
the  signs  of  inflammation,  and  with  a  profuse,  generally  puru- 
lent, and  sometimes  blood-stained  discharge.  There  is  pain  on 
urination  and  defaecation,  and  tenesmus.  The  inflammation  may 
spread  to  the  uterus,  and  thence  to  the  Fallopian  tubes,  or  to  the 
urethra  and  Bartholin's  glands.  Saline  purgatives,  rest,  warm 
hip-baths,  and  cleansing  the  part  with  Condy's  lotion,  followed 
by  astringent  injections,  is  the  proper  treatment. 

Tumors  of  the  vagina  are   rare,  and  require  no  special  notice. 

Cysts  of  the  vagina  are  occasionally,  though  rarely,  met  with 
as  the  result  of  the  distension  of  the  mucous  follicles  ;  and  others 
are  described  as  originating  from  remnants  of  the  Wolffian  duct, 
or  from  the  dilatation  of  lymphatics.  They  should  be  treated  by 
the  excision  of  a  portion  of  the  cyst-wall,  combined  with  cauter- 
ization. 

Vesico-vaginal  fistula,  when  not  due  to  malignant  disease, 
are  generally  the  result  of  sloughing,  consequent  upon  the  press- 
ure of  the  child's  head  in  a  prolonged  or  instrumental  labor, 
though  they  may  be  occasionally  produced  in  other  ways,  as  from 
the  impaction  of  a  foreign  body  in  the  vagina  or  urethra,  injury, 
etc.  They  give  rise  to  incontinence  of  urine,  and  are  productive 
of  great  inconvenience.  They  may  be  so  small  as  merely  to  ad- 
mit a  probe,  or  nearly  the  whole  of  the  anterior  wall  of  the  vagina 
may  be  destroyed.  The  common  situation  is  just  below  the  neck 
of  the  uterus.  Treatment. — Where  the  fistula  is  very  small, 
touching  it  with  the  actual  cautery  may  succeed  in  closing  it  ;  but 


752  DISEASES   OF   REGIONS. 

a  plastic  operation  is  usually  necessary.  The  rectum  having  been 
cleared  by  an  enema,  the  patient  should  be  placed  in  the  lith- 
otomy position,  and  a  duck-bill  speculum  introduced.  The  edges 
of  the  fistula  should  then  be  pared,  and  brought  together  with 
silver-wire  or  silk-worm-gut  suture.  The  sutures  should  be  placed 
sufficiently  close  to  prevent  the  passage  of  urine  between  them. 
A  good  way  of  testing  if  they  are  close  enough,  is  to  inject  milk 
into  the  bladder,  so  that  should  any  escape  through  the  fistula,  its 
color  will  make  it  visible.  Smith's  needle  will  be  found  very  con- 
venient if  wire  sutures  are  used.  The  bladder  should  be  emptied 
by  a  catheter  at  regular  intervals ;  the  vagina  syringed  out  with 
an  antiseptic  solution,  and  dusted  with  powdered  iodoform ;  and 
the  bowels  kept  confined  for  a  week  or  more. 

Recto-vaginal  fistul^c  may  occur  from  causes  similar  to  those 
leading  to  the  vesico-vaginal  variety ;  they  are  also  sometimes 
congenital.  They  are  commonly  situated  just  within  the  entrance 
to  the  vagina,  and  may  be  closed  in  the  same  way  as  the  vesico- 
vaginal fistula. 

Utero-vesical  and  UTERO-RECiAL  FiSTUL/E  may  also  occur,  but 
are  too  rare  to  require  any  description  here. 

Imperforate  hymen,  if  overlooked  till  after  puberty,  is  a  seri- 
ous affection,  as  the  vagina,  and  later  the  uterus  and  Fallopian 
tubes,  may  become  distended  with  the  retained  blood,  conditions 
known  respectively  as  hainaio-kolpos,  hocinaio-melra  and  hcemalo- 
salpivx.  If  relief  is  not  obtained,  enormous  distension  may 
occur,  and  the  tubes  or  uterus  give  way,  setting  up  peritonitis. 
Or  the  hymen  itself  may  yield,  and  all  end  well ;  or  saprsemia 
may  occur  from  putrefaction  of  the  blood  and  absorption  of  the 
septic  products  on  the  admission  of  air;  or  septic  peritonitis  may 
be  produced  by  the  sudden  alteration  of  pressure  or  the  contrac- 
tion of  the  uterus  causing  rupture  of  the  tubes  and  escape  of 
fluid  into  the  peritoneum.  Treatment. — Before  puberty,  division 
or  excision  of  a  portion  of  the  hymen  is  a  simple  and  safe  oper- 
ation ;  but  when  distension  has  occurred,  it  is  attended  with  great 
risk,  as  if  a  free  opening  is  made  there  is  danger  of  peritonitis 
from  the  same  causes  as  when  spontaneous  rupture  takes  place, 
and  if  a  small  opening  is  made,  of  saprpemina  from  decomi)osi- 
tion.  The  safest  plan,  perhaps,  is  to  make  a  small  opening,  and 
to  keep  the  parts  aseptic  by  iodoform  or  the  like. 

Mai J'ORMAi IONS  of  the,  vagina. — Atresia  or  imperforate  vai:;ina. 
The  vagina  may  be  completely  absent,  or  divided  by  a  transverse 
or  horizontal  septum.  ""J'he  uterus  and  ovaries  may  also  be  ab- 
sent, and  no  trouble  will  then  result;  but  when  these  are  present, 
similar  results  to  those  described  under  imperforate  hymen  may 
follow.     Atresia  of  the  vagina  may  also  be  due  to  adhesions  or 


OVARIAN   TUMORS.  753 

the  contraction  of  cicatrices  following  ulceration,  etc.  The  ab- 
sence of  the  uterus  may  be  determined  by  introducing  a  catheter 
into  the  bladder  and  the  finger  into  the  rectum,  when  the  two 
will  be  felt  to  be  in  close  apposition.  In  such  a  case  no  operation 
should  be  undertaken,  as  all  that  would  be  achieved  would  be  to 
open  the  peritoneal  cavity.  When  the  uterus  and  ovaries  are 
present,  and  distension  has  occurred,  if  the  vagina  is  only  par- 
tially absent  an  attempt  maybe  made  to  form  a  vagina  by  dissect- 
ing carefully  through  the  tissues  between  the  bladder  and  the 
rectum  in  the  direction  of  the  os.  When  this  is  found,  the  parts 
must  then  he  prevented  from  re-adhering  by  introducing  lami- 
naria  tents,  frequent  digital  examinations,  etc.  Where  the  vagina 
is  completely  absent  the  uterus  may  become  distended,  and  may 
then  either  be  punctured  through  the  rectum,  or  in  some  instances, 
together  with  the  ovaries,  be  removed. 

CvsTOCELE  AND  RECTOCELE  are  the  names  given  to  a  prolapse  of 
the  anterior  and  posterior  wall  of  the  vagina  respectively.  In  the 
former  the  bladder  of  course  protrudes;  in  the  latter,  the  rectum 
or  pouch  of  Douglas,  which  may  contain  some  small  intestine. 
Partial  prolapse  of  either  wall  is  a  frequent  accompaniment  of  ex- 
tensive ruptures  of  the  perineum.  These  affections  generally  fall 
under  the  care  of  the  Obstetrician,  but  at  times  the  Surgeon  may 
be  called  upon  to  perform  a  plastic  operation  for  their  cure.  This 
consists  in  removing  a  portion  of  mucous  membrane  from  the 
upper  or  lower  wall  of  the  vagina  as  the  case  may  be,  bringing 
the  raw  surfaces  together  with  sutures,  and  keeping  the  bladder 
empty  with  a  catheter  till  firm  union  has  taken  place. 

DISEASES    OF    THE    OVARIES    AND    FALLOPIAN    'JUBES. 

Ovarian  tumors. — Ovarian  tumors  may  grow  either  from  the 
ovary  itself,  or  from  the  broad  ligament,  and  may  be  either  solid 
or  cystic.  Amongst  the  solid  tumors,  which  are  rare,  carcinoma 
and  sarcoma  are  the  most  common.  Amongst  the  cystic  the  so- 
called  multilocular  cysts  are  most  frequently  met  with  ;  but  other 
forms,  as  the  unilocular,  the  dermind,  and  the  parovarian  cysts, 
may  also  occur.  For  a  description  of  these  tumors  and  of  their 
pathologv,  which,  at  the  best,  is  but  imperfectly  understood,  the 
reader  is  referred  to  a  special  work  on  the  subject. 

Symptotns. — There  m.ay  be  no  symptoms  at  first  ;  but  as  the 
tumor  increases  in  size,  it  gradually  encroaches  on  the  space 
normally  allotted  to  the  pelvic  and  abdominal  viscera,  giving  rise 
to  one  or  more  of  the  following  symptoms  :  Thus,  from  pressure 
on  the  bladder  and  rectum  there  may  be  increased  micturition 
and  constipation  ;  from  pressure  on  the  iliac  vessels,  oedema  of 


754  DISEASES    OF    REGIONS. 

the  lower  limbs  and  genitals  ;  from  pressure  on  the  sacral  and 
lumbar  plexus,  pains  in  the  back,  pudenda,  and  legs  ;  from  pres- 
sure on  the  stomach,  nausea  and  vomiting ;  on  the  intestines, 
diarrhoea  or  colicky  pains ;  on  the  portal  vein,  ascites  and 
haemorrhoids ;  on  the  kidneys  and  ureters,  albuminous  and 
highly-concentrated  urine,  rich  in  urates.  Later,  as  the  tumor 
extends  upwards,  there  will  be  embarrassed  breathing  and  dys- 
pnoea from  pressure,  on  the  heart  and  lungs  ;  while  finally  emaci- 
ation sets  in,  and  the  patient  dies  of  exhaustion,  if  not  carried  off 
by  an  intercurrent  attack  of  peritonitis  and  rupture  of  the  cyst. 

The  physical  signs  vary  according  to  the  size  of  the  cyst,  and 
the  diagnosis  at  first  may  be  attended  with  some  difiiculty.  But 
as  the  cyst  rises  out  of  the  pelvis,  and  the  abdomen  becomes 
gradually  distended,  the  condition  known  as  ovarian  dropsy  is 
produced,  the  physical  signs  of  which  somewhat  resemble  dropsy 
of  the  peritoneum  {ascites)  depending  on  visceral  disease.  In 
ovarian  dropsy  the  abdomen  is  dull  in  front,  resonant  in  the 
flanks  ;  the  dulness  is  not  altered  by  position  ;  and  the  distension 
is  greatest  in  the  hypogastric  and  umbilical  regions.  Whereas  in 
ascites  the  abdomen  is  resonant  in  front,  dull  in  the  flanks ;  the 
dulness  is  altered  by  position,  the  dull  flank  becoming  resonant 
when  the  patient  is  placed  on  the  opposite  side  ;  the  distension 
is  most  marked  laterally ;  and  the  circumference  is  greatest  at 
the  level  of  the  umbilicus.  In  both  a  percussion  wave  or  thrill 
generally  exists,  but  in  ovarian  disease  it  is  usually  limited  to  the 
dull  area,  whilst  in  ascites  it  is  as  a  rule  felt  all  over.  In  ascites, 
moreover,  there  is  probably  other  evidence  of  the  visceral  disease 
which  is  producing  the  dropsy  ;  and  if  the  abdomen  is  punctured 
the  fluid  will  be  found  to  be  of  a  thin  and  serous  character.  In 
ovarian  disease  the  utems  is  usually  displaced.  An  ovarian  tumor 
may  also  have  to  be  distinguished  from  pregnancy,  tympanites, 
encysted  dropsy  of  the  peritoneum,  tumors  of  the  omentum,  sub- 
peritoneal cysts  and  tumors,  fibroids  of  the  uterus,  pelvic 
hajmatocele  and  abscess,  extra-uterine  pregnancy,  and  a  distended 
bladder;  but  the  differential  diagnosis  cannot  be  attempted  in  a 
work  of  this  character.  Having,  however,  determined  that  the 
disease  is  an  ovarian  cyst,  the  next  point  to  make  out  is  whether 
it  is  unilocular  or  multilocular,  free  or  adherent.  The  mulliloc- 
itlar  cyst  is  usually  irregular ;  fluctuation  is  absent,  or  more 
marked  in  some  parts  than  in  others  ;  and  there  is  no  thrill  or 
fluctuation  wave  on  percussion,  unless  one  of  the  cysts  has  at- 
tained a  ])reponderating  size.  The  unilocular  cyst  is  smooth, 
rounded,  regular,  and  elastic  ;  fluctuation  is  felt  equally  distrib- 
uted over  the  whole  of  the  dull  area.  If  adhesions  are  present 
the  cyst  is  fixed,  unless  they  take  the  form  of  elongated  bands,  in 


OVARIOTOMY.  755 

which  case  a  friction  rub  or  sound  may  be  felt  or  heard.  The 
nmbihcus  moves  with  the  cyst ;  but  no  movement  is  detected  on 
examination  by  the  rectum  or  vagina.  If  thei'e  are  no  adhesions 
the  cyst  moves  on  respiration,  but  the  umbiUcus  does  not  move 
with  the  cyst,  and  the  cyst  is  not  found  fixed  on  examination  by 
the  rectum  or  vagina.  Such  are  the  chief  points  to  be  attended 
to ;  but  often  the  signs  are  delusive,  and  where  a  tumor  is  ex- 
pected to  be  of  a  unilocular  character  and  free,  it  may  be  found 
to  be  multilocular  or  solid  and  extensively  adherent  to  the  neigh- 
boring parts. 

Treatment. — The  only  effectual  treatment  is  to  remove  the 
tumor  by  the  operation  of  ovariotomy,  an  operation  which,  though 
formerly  attended  with  a  high  rate  of  mortality,  may  now  be  said 
to  be  one  of  the  most  successful  of  the  major  operations  in  sur- 
gery. Repeated  tappings,  and  tapping  and  injecting  with  tincture 
of  iodine,  have  now  very  rightly  almost  ceased  to  be  employed, 
although  tapping  may  still  at  times  be  called  for  under  excep- 
tional circumstances,  which  cannot  here  be  discussed.  Before 
ovariotomy  is  undertaken,  however,  the  patient  should  be  very 
carefully  prepared  by  attention  to  the  bowels  and  kidneys,  any 
congested  condition  of  the  latter  being  relieved  by  aperients, 
diaphoretics,  warm  baths,  and  the  administration  of  citrate  of 
potash,  lithia,  etc. 

OvARiOTOiNiY. — The  patient  having  been  well  wrapped  up,  with 
woolen  stockings  on  the  legs,  etc.,  the  bladder  emptied  by  a 
catheter,  the  skin  of  the  abdomen  previously  cleansed  with  soap 
and  water  and  antiseptics,  and  the  anaesthetic  administered,  a 
mackintosh  cloth  with  an  oval  opening  is  placed  over  the  abdo- 
men and  secured  round  the  opening  to  the  skin  by  adhesive  ma- 
terial. The  parts  should  then  be  again  sponged  with  antiseptics, 
and  an  incision  made  in  the  middle  line  about  three  inches  long 
midway  between  the  pubes  and  the  umbilicus  (Fig.  284,  a). 
This  incision  may  be  afterwards  prolonged  if  necessary.  The 
peritoneum  having  been  reached,  and  all  haemorrhage  stopped 
with  pressure  forceps^  the  peritoneal  cavity  is  carefully  opened  on 
a  director,  the  hand  introduced,  and  adhesions  felt  for.  If  the 
cyst  is  free,  Spencer  Wells'  trocar  and  cannula  are  thrust  through 
the  cyst-wall,  the  fluid  evacuated,  and  the  cyst  gradually  drawn 
out  through  the  wound  as  it  is  reduced  in  size  by  the  escape  of 
the  fluid.  The  pedicle  is  now  transfixed  by  a  long  needle  armed 
with  a  suture  of  China  silk,  the  suture  severed,  and  the  needle 
withdrawn.  The  two  portions  of  suture  are  next  twisted,  and  the 
pedicle  firmly  tied  on  both  sides.  The  ])edicle  is  then  divided  on 
the  cyst  aspect,  and  the  cyst  removed,  care  being  taken  to  pre- 
vent any  of  its  contents  escaping  into  the  abdomen.     If  the  cut 


756  DISEASES   OF   REGIONS. 

surface  of  the  pedicle  appears  dry,  the  sutures  by  which  it  is  tied 
are  cut  off  short,  and  it  is  allowed  to  slip  back  into  the  pelvis  ;  but 
if  any  bleeding  point  is  seen,  this  must  first  be  secured.  Should 
adhesions-  be  felt  on  opening  the  abdomen,  they  should  be  care- 
fully broken  down  by  the  hand,  or  divided  if  necessary,  care 
being  taken  not  to  injure  the  intestines  and  to  secure  all  bleeding 
vessels.  After  the  cyst  has  been  removed,  the  other  ovary  should 
be  examined,  and  if  diseased,  also  removed.  The  sponging-out 
or  irrigation  of  the  abdomen  is  now  begun,  and  must  be  continued 
as  long  as  any  blood-stained  fluid  can  be  squeezed  from  the 
sponges.  The  sponges  should  be  thrust  down  deeply  into  Doug- 
las's pouch,  and  when  all  the  blood-stained  fluid  has  been  re- 
moved from  this  part  of  the  peritoneum,  a  sponge  attached  by  a 
string  should  be  left  there  until  just  before  closing  the  wound,  to 
ensure  that  no  collection  remains  in  this  dependent  situation.  If 
irrigation  is  employed,  an  india-rubber  tube  attached  to  a  can 
containing  the  irrigating  fluid  should  be  passed  in  various  direc- 
tions into  the  abdominal  cavity,  and  the  fluid  allowed  to  flow  until 
it  runs  away  perfectly  clear.  The  irrigating  fluid  may  consist  of 
boiled  water  at  a  temperature  of  98°,  or  water  containing  some 
mild  antiseptic,  as  boracic  acid.  Mr.  Tait  uses  ordinary  tap 
water.  A  large  soft  sponge  is  finally  placed  over  the  surface  of 
the  intestines  whilst  the  deep  parietal  sutures  are  being  intro- 
duced. These  should  be  passed  about  half  an  inch  apart,  and 
made  to  include  the  skin,  peritoneum,  and  edge  of  the  muscles, 
so  that  when  tied  two  free  surfaces  of  peritoneum  are  in  contact. 
The  sutures  being  all  in  situ,  the  flat  sponge  and  the  sponge  in 
Douglas's  pouch  are  withdrawn,  and  the  wcund  is  closed  by  tying 
the  sutures.  Superficial  sutures  are  next  introduced  between 
the  deep,  to  ensure  the  accurate  appositition  of  the  skin.  The 
mackintosh  is  now  removed,  a  gauze-dressing  firmly  secured  by 
strips  of  strapping,  and  a  flannel  bandage  applied  over  all.  Under 
some  circumstances,  as  where  many  adhesions  have  been  broken 
down,  and  there  is  likely  to  be  oozing  into  the  pelvis,  or  where 
the  peritoneum  has  been  accidentally  soiled  by  septic  material  of 
any  kind,  a  drain-tube  should  be  placed  in  the  wound.  The  tube 
is  passed  through  a  tightly-fitting  hole  in  the  centre  of  a  sheet  of 
thin  rubber  (Fig.  363).  The  end  of  the  tube  should  then  be 
placed  in  the  bottom  of  Douglas's  pouch,  and  the  parietal  wound 
closed  except  at  the  situation  of  the  tube,  and  dressed  with  anti- 
septic gauze  placed  between  the  skin  and  the  rubber  sheet. 
Over  the  mouth  of  the  tube  an  aseptic  sponge  is  laid,  and  the 
rubber  sheet  wrapped  around  it  so  as  to  prevent  any  discharge 
from  the  tube  reaching  the  permanent  dressing.  The  rubber  is 
unfolded  at  intervals,  the  sponge  removed,  and  a  capillary  pipette 


SALPINGITIS. 


757 


passed  down  the  tube  to  draw  off  any  discharge  that  has  collected. 
The  tube  is  retained  till  the  discharge  ceases  to  collect  in  it  and 
becomes  of  a  serious  character.  The  after  treatment  consists  in 
keeping  the  patient  at  rest,  soothing  pain  and  procuring  sleep  by 
morphia,  emptying  the  bladder  at  regular  intervals  by  the  cathe- 
ter, and  allaying  vomiting  if  present  by  ice  or  teaspoonfuls  of  hot 
water,  or  if  intractable  by  washing  out  the  stomach.  Tympanites 
is  greatly  relieved  by  the  occasional  passage  of  a  long  rectal  tube. 
No  food  should  be  given  for  the  first  twenty-four  hours;  then 
nutrient  enemata  should  be  administered,  and  after  three  days  a 

Fig.  363. 


Method  of  draining  after   ovariotomy.     A  A.  Rubber   sheet.     D  D.  Dressings,     s  s.   Integu- 
ments.    T.  Drain-tube.     I  i.  Intestines.     P,  Pipette. 


return  to  slop  diet  should  be  cautiously  made.  The  stitches 
may  be  removed  from  the  third  to  the  seventh  day,  and  the 
wound  then  supported  by  strapping.  If  signs  of  peritonitis  ap- 
pear, Mr.  Tait  gives  a  turpentine  enema  and  saline  purge.  See 
Peritonitis  (p.  393). 

Salpingitis — Hvdro-salpinx — Pvo-salpinx — H^mato-salpinx. 
— As  the  result  of  gonorrhoea,  inflammation  of  the  uterus  or  pel- 
vic peritoneum,  and  occasionally  of  parturition,  the  Fallopian  tubes 
may  become  inflamed  {salpingitis),  and  their  orifices  adherent, 
and  as  a  consequence  they  may  become  distended  with  serum 
{hydro-sa/pinx)  (Fig.  364)  or  with  pus  {pyo-salpinx)  ;  whilst 
much  more  rarely,  as  the  result  of  an  injury  or  from  obstruction 
in  the  uterus  or  vagina,  they  may  become  distended  with  blood 


758 


DISEASES   OF   REGIONS. 


{Jiceuiato-salpiux^ .  The  symptoms  are  pain,  worse  on  exertion, 
straining,  or  coitus  ;  and  intensely  painful,  irregular  or  profuse 
menstruation,  together  with  a  history  of  uterine  or  ovarian 
trouble.  On  examination  an  ovoid,  generally  tender  perhaps 
fluctuating  swelling  will  be  felt  externally  and  through  the  roof  of 
the  vagina,  and  on  both  sides  if  both  tubes  are  affected.     The 

swelling  will  be  movable  or 
F"^- 3^4-  immovable  according    as  it 

is  free  or  adherent,  and  may 
be  distinguished  from  an 
ovarian  cyst  by  its  shape, 
and  by  being  felt  anteriorly 
rather  than  on  either  side  of 
the  neck  of  the  uterus.  Pyo- 
salpinx  may  generally  be 
distinguished  from  hydro- 
salpinx by  the  occurrence  of 
rigors  and  fever ;  but  a 
diagnosis  is  often  impossible. 
7  '/ra  tin  en  t.  —  The  re  m  o  - 
val  of  the  tube  and  ovary  in 
the  case  of  hydro-  or  pyo- 
salpinx  is  the  treatment  that 
has  been  adopted ;  but  it 
should  only  be  done  when 
the  symptoms  are  severe. 
Tapping  through  the  vagina 
has  not  been  attended  with 
success.  The  operation  of 
removal  may  be  done  in  a  manner  similar  to  oophorectomy. 
Hsemato-salpinx,  as  a  rule,  requires  no  active  treatment. 

Oophorectomy,  or  Battky's  operation,  consists  in  the  removal 
of  the  ovaries,  and  has  been  done  for  inflammation,  neuralgia, 
amenorrhcen,  mollities  ossium,  fibroids,  etc.  The  operation  is 
performed  like  ovariotomy.  A  small  incision  being  made  in  the 
linea  alba,  midway  between  the  umbilicus  and  the  pubes,  two 
fingers  are  introduced  into  the  peritoneal  cavity,  and  first  one, 
and  then  the  other  ovary  brought  out  of  the  wound.  The  pedi- 
cle, which  consists  of  broad  ligament  and  its  contained  structures, 
is  transfixed  and  ligatured  as  in  ovariotomy,  the  ovary  cut  off,  and 
the  pedicle  dropped  back  into  the  abdomen. 

Hvs'iEREOioMY,  OR  RKMOVAL  OF  THE  UTERUS,  may  be  donc 
through  the  vagina  (Schrocifrr's  operation)  or  through  an  incision 
in  the  abrlominal  walls  {Frei/mPs  operation).  In  the  former,  an 
incision  is  made  through  the  vaginal  mucous  membrane  around 


Double  hydro-salpiiix.  u.  IJladder.  K.  Rectum. 
R.  T.  Right  tube  opened.  L.  T.  Left  tube. 
O.  Ovary,  u.  I'terus.  (Si.  Barlholomcw's 
Hospital  Mu.scum). 


ACUTE    INFLAMMATION.  .  759 

the  cervix,  the  peritoneal  cavity  opened,  the  broad  ligament 
transfixed  and  ligatured,  and  the  uterus  severed  from  its  connec- 
tions and  drawn  out  through  the  vagina.  In  the  operation 
through  the  abdominal  wall,  the  peritoneal  cavity  is  opened,  as  in 
ovariotomy ;  the  broad  ligament  transfixed  and  ligatured  ;  and 
the  uterus  drawn  up  from  the  pelvis  and  carefully  severed  from 
its  connections.  For  a  detailed  account  of  these  operations, 
however,  the  student  is  referred  to  a  larger  work. 

DISEASES    OF    THE    BREAST. 

Facet's  disease  of  the  nipple,  sometimes  spoken  of  as  eczema, 
is  an  intractable  form  of  ulceration  around  the  nipple.  It  lasts  for 
many  years,  and  yields  to  no  treatment.  A  considerable  propor- 
tion of  cases  develop  carcinoma  of  the  breast.  Recently  small 
vegetable  parasites  known  as  psorosperms  have  been  found  in  the 
tissues  surrounding  the  ulcer,  and  are  believed  by  some  Patholo- 
gists to  be  the  exciting  cause  of  the  disease.  Treatment. — When 
all  mild  measures  are  unavailing,  many  Surgeons  recommend 
amputation  of  the  breast  for  fear  of  cancer  subsequently  forming. 

Neuralgfa  of  the  breast  is  not  uncommon  in  young  unmarried 
women,  and  appears  to  be  frequently  due  to  some  ovarian  disturb- 
ance. The  pain  is  often  severe,  perhaps  shooting  down  the  arm, 
and  may  be  constant  or  periodic  ;  whilst  the  skin  over  the  breast, 
as  well  as  the  gland  itself,  is  exceedingly  sensitive  on  handling. 
Nothing,  except  at  times  a  slight  fulness,  can  be  detected  on  ex- 
amination. The  treatment  consists  in  improving  the  general 
health  by  tonics,  cold  baths,  and  outdoor  exercise,  and  in  regu- 
lating the  ovarian  functions.  No  local  treatment  is  necessary ; 
indeed,  the  patient's  attention  should  be  taken  off  the  breast  as 
much  as  possible. 

Inflammation  of  the  breast  may  occur  at  any  age,  and  in  the 
male  as  well  as  the  female.  In  in/ants  it  is  sometimes  attended 
with  a  serous  or  milky  discharge  from  the  nipple,  and  is  often 
made  worse  by  ignorant  nurses  applying  friction  to  "rub  away 
the  milk."  At  or  adont  puberty  it  is  met  with  in  boys  as  well  as 
in  girls,  but  more  frequently  in  the  latter.  Often  beyond  the 
patient  appearing  somewhat  out  of  health  no  cause  can  be  dis- 
covered, although  in  hospital  patients  a  history  of  a  blow  is  not 
uncommon.  The  inflammation  may  clear  up,  or  terminate  in  an 
abscess. 

Acute  inflammation,  however,  most  frequently  occurs  during 
lactation,  especially  in  primiparse,  and  generally  during  the  first 
month  after  parturition.  It  then  appears  to  be  most  often  due  to 
the  irritation  of  the  nipple  by  the  child  sucking,  particularly  when 


760  DISEASES   OF   REGIONS. 

the  nipple  is  shrunken  or  retracted,  or  is  in  a  cracked  condition. 
Occasionally  it  is  the  result  of  excessive  secretion  of  milk,  and  con- 
sequent hyperccsthesia  of  the  ducts  ;  or  it  may  not  appear  till  later 
during  the  period  of  lactation,  when  the  patient's  powers  have  been 
pulled  down  by  long  suckling. 

Syifipfo/ns. — A  feeling  of  uneasiness  in  the  breast,  then  a  chill 
or  sHght  rigor,  followed  by  fever  and  the  local  signs  of  inflamma- 
tion, and  often  subsequently  of  abscess. 

Treatment. — The  breast  should  be  placed  at  perfect  rest  by 
slinging  it  in  a  silk  handkerchief  passed  over  the  shoulder,  and  by 
taking  away  the  infant  from  the  sound  as  well  as  from  the  affected 
side ;  the  milk,  if  the  tension  is  great,  should  be  drawn  oft 
regularly  by  the  breast  pump ;  and  belladonna  and  glycerine 
appHed  to  diminish  the  secretion,  and  opium  or  poppy  fomenta- 
tions to  relieve  pain.  Signs  of  abscess  must  be  watched  for  and 
an  early  incision  made.  A  smart  saline  purge,  followed  by  saline 
laxatives  and  light  nutritious  slop  diet,  is  usually  necessary. 

Abscess  of  the  breast  may  occur  in  three  situations: — i. 
Superficial  to  the  gland  {supra-mammary  abscess')  ;  2.  In  the  sub- 
stance of  the  gland  {^intra-mammary  abscess)  ;  and  3.  Behind  the 
gland  { post  mammary  abscess),  t.  The  supra-mammary  variety 
resembles  an  abscess  in  any  other  situation,  and  requires  no  further 
comment.  2.  The  intra-mammary,  which  is  generally  the  result 
of  inflammation  occuring  during  lactation,  may  be  confined  to  one 
part  of  the  gland  ;  or  pus  may  be  formed  in  several  situations  at 
the  same  time,  and  if  not  let  out  by  timely  incisions  may  riddle  the 
breast  in  all  directions.  3.  In  the  post-mammary,  the  inflamma- 
tion begins  either  in  the  cellular  tissue  behind  the  breast,  or  in  the 
posterior  lobes  of  the  gland,  the  resulting  abscess  then  bursting 
into  the  cellular  tissue  behind  the  breast.  The  whole  breast  is 
pushed  forward  and  presents  a  characteristic  conical  appearance. 
There  is  deep-seated  and  throbbing  pain,  increased  on  moving  the 
arm,  with  some  oedema  and  mottled  redness  of  the  skin.  The  pus 
usually  gravitates  towards  the  lower  and  outer  part  of  the  breast, 
where  the  abscesss  commonly  points;  or  it  may  burrow  through 
the  gland,  producing  fistulous  tracks  which  are  often  very  difficult 
to  heal. 

Treatment. —  In  all  varieties  an  early  and  free  incision  should  be 
made,  preferably  under  an  anaesthetic.  In  the  intra-mammary 
the  incision  should  radiate  from  the  nipple,  so  as  not  to  cut  across 
the  galactophorous  ducts  ;  and  should  be  free,  not  a  mere  puncture, 
lest  the  abscess  cavity  degenerate  into  a  sinus.  In  the  post- 
mammary  the  incision  should  by  j^reference  be  made  at  the  most 
dependent  part  to  ensure  an  efficient  drain,  though  of  course  pus 
wherever  jjointing  must  be  let  out.  Should  sinuses  or  fistulas  form, 


CHRONIC   LOBULAR   INFLA1\OL4T10N   OF   THE    BREAST.  76 1 

they  should  be  laid  freely  open  and  thoroughly  drained,  after  be- 
ing scraped  by  a  Volkmann's  spoon.  The  strength  should  be 
supported  by  a  generous  diet,  and  ammonia  and  bark  or  quinine 
and  iron  given  internally,  together  with  stimulants,  if  indicated. 

Chronic  lobular  inflammation  of  the  breast,  which  has  been 
described  by  various  names,  as  lobular  induration,  chronic  hyper- 
trophy, chronic  interstitial  mastitis,  etc.,  affects  generally  one  lobe, 
or  limited  portions  of  the  gland,  and  is  of  much  interest,  in  that  it 
is  liable  to  be  mistaken  for  a  tumor.  It  is  said  to  be  most  fre- 
quent in  married  women  beyond  the  child-bearing  period  of  life  ; 
but  my  own  experience  is  that  it  is  often  met  with  in  young  and 
unmarried  women. 

Cause  and  Fathology. — It  is  generally  attributed  to  ovarian  dis- 
turbance. A  small-cell-infiltration  occurs  in  the  connective  tissue 
of  the  affected  lobe,  with  increased  proliferation  of  the  epithelium. 
Later  the  cells  or  fibroblasts  form  fibrous  tissue,  which  contracts, 
pressing  upon  and  obliterating  the  ducts  and  acini,  and  causing 
fatty  degeneration  of  the  epithelium  lining  them.  Should  some 
of  the  acini  escape  the  pressure  which  has  obliterated  the  ducts 
leading  from  them,  small  cysts  may  be  formed  ;  but  such  cysts 
never  attain  a  large  size,  in  consequence  of  the  unyielding  nature 
of  the  fibrous  tissue  by  which  they  are  surrounded. 

Symptoms. — The  patient  usually  complains  of  a  swelling,  and 
sometimes  of  pain  in  the  breast.  On  grasping  the  breast  between 
the  fingers  the  hypertrophied  portion  feels  hke  a  tumor,  but  on 
drawing  it  from  the  nipple  so  as  to  make  the  lactiferous  ducts 
tense,  it  is  found  to  be  p;irt  of  the  mamma,  and  on  pressing  the 
breast  back  on  the  ribs  with  the  flat  of  the  hand,  no  distinct  tumor 
is  felt,  nor  anything  like  the  resistance  of  a  new  growth.  Further, 
the  swelling  is  usually  of  a  wedge-shape,  with  its  apex  towards  the 
nipple,  and  has  not  the  stony  hardness  of  scirrhus  ;  and  there  may 
be  a  second  nodule  in  the  same  breast,  or  in  the  breast  of  the  op- 
posite side.  The  axillary  glands  are  sometimes  enlarged,  but  are 
not  indurated,  and  the  pain  often  follows,  as  pointed  out  by  Mr. 
Birkett,  the  distribution  of  one  or  more  intercostal  nerves,  the 
slightest  pressure  upon  which  as  they  issue  from  the  thorax  causes 
acute  pain.  The  above  signs  will  usually  serve  to  distinguish  the 
affection  from  scirrhous  carcinoma.  Should,  however,  as  occa- 
sionally happens,  the  nipple  be  retracted,  the  skin  dimpled  from 
the  contraction  of  the  fibrous  septa,  the  surface  of  the  gland  ren- 
dered nodular  by  the  presence  of  several  tense  cysts,  and  the 
patient  moreover  be  about  the  age  at  which  carcinoma  is  com- 
mon, it  may  be  difficult  to  diagnose  between  them,  especially  if 
the  breast  is  voluminous,  so  that  the  characters  of  the  swelling  are 
obscured.  Under  such  circumstances  it  is  quite  justifiable  to 
32* 


762  DISEASES   OF   REGIONS. 

make  an  exploratory  incision,  after  having  explained  the  import- 
ance of  a  correct  diagnosis  to  the  patient. 

Treatment. — Iron  and  quinine  or  the  mineral  acids  are  often 
indicated,  and  with  these  some  combine  the  iodide  of  potassium. 
Locally  a  belladonna  plaster  may  be  applied,  or  the  stays  dis- 
pensed with  to  prevent  friction,  or  a  thick  layer  of  cotton-wool 
placed  between  them  and  the  breast.  Inunction  with  iodide  of 
potassium  ointment,  or  with  oleate  of  mercury,  and  strapping  the 
breast,  are  also  recommended.  Whatever  treatment  is  adopted, 
it  should  be  persevered  in  for  several  months. 

There  is  a  condition  oi  Hypertrophy  often  met  with  in  lads 
about  the  age  of  puberty,  and  in  girls  a  little  below  that  age.  The 
breast  enlarges  slowly,  often  painlessly,  generally  on  one,  some- 
times on  both  sides.  There  are  no  signs  of  inflammation.  Under 
the  influence  of  belladonna  plaster  applied  for  some  months,  which 
probably  owes  its  efficacy  to  the  fact  that  it  prevents  the  patient 
irritating  the  breast  by  constantly  feeling  it,  the  hypertrophy  usu- 
ally subsides.  Of  its  exact  pathological  condition  I  am  not  aware, 
but  it  is  generallly  thought  to  be  of  a  chronic  inflammatory  nature. 

Tumors  of  the  breast. — The  tumor  by  far  the  most  frequently 
met  with  in  this  situation  is  the  acinous  carcinoma  {scirrhiis), 
which  is  due  to  the  proliferation  of  the  epithelium  lining  the  acini 
or  the  small  ducts.  C'ertain  of  the  connective-tissue  tumors 
(fibroviata,  sarcomata),  springing  from  the  periacinous  connec- 
tive tissue,  are  also  of  frequent  occurrence.  They  seldom,  how- 
ever, occur  pure,  but  are  nearly  always  mixed  with  elements  re- 
sembling the  tissue  of  the  breast  itself  (adcnoi/iatous  tissue),  and 
hence  are  spoken  of  as  adeno-fibroma,  adeno-sarcoma,  adeno- 
myxoma.  Whether  these  adenomatous  elements  are  the  normal 
breast-tissue,  which  has  become  surrounded  and  enclosed  in  the 
fibrous  or  sarcomatous  growth  as  the  ca!je  may  be,  or  whether  it 
is  an  abortive  formation  of  the  gland-tissue,  is  not  agreed  upon  by 
pathologists.  Most,  however,  believe  that  it  is  a  new  formation. 
More  rarely  the  gland-tissue  may  constitute  the  chief  bulk  of  the 
\mxs\ox  (pure  adenoma).  'I'he  tumors  composing  this  class  were 
formerly  spoken  of  collectively  as  chronic  mammary  glandular 
tumors.  At  times  cysts  are  developed  in  connection  with  them, 
and  they  are  then  designated  cystic  adeno-Jihronia,  cystic  adcno- 
saj'coma,  cystic  adeno-myxoma,  etc.  Various  other  firms  of  tumor, 
viz.,  tumors  composed  of  fat,  cartilage,  vessel-tis-ue,  nerve-tissue, 
etc.,  have  also  been  met  with  in  the  breast,  but  are  exceedingly 
rare. 

Purr  adenomata  are  very  rare.  They  occur  as  circumscribed 
ovoid  tumors  surrounded  by  a  capsule  of  connective  tissue.  On 
section  they  appear  smooth,  lobed,  white  or  tinged  with  pink. 


ADENO-SARCOMATA.  763 

with  here  and  there  small  cavities  and  occasionally  distinct  cysts. 
Their  general  characters  have  already  been  given  under  Ti/inors. 
All  that  need  here  be  repeated  is  that  they  consist  of  acini  and 
ducts  surrounded  by  a  small  amount  of  vascular  connective  tissue  ; 
in  short,  that  they  resemble  the  breast  preparing  for  lactation, 
save  that  the  acini  and  ducts  do  not  form  distinct  lobules  with  an 
excretory  duct,  as  in  the  lactating  breast.  Further,  the  epithelium 
does  not  penetrate  the  membrana  propria  and  grow  into  the  in- 
ter-tubular and  inter-acinous  connective  tissue,  a  point  of  import- 
ance as  distinguishing  them  from  carcinoma. 

Signs. — They  are  most  often  met  with  in  women  between  the 
ages  of  thirty  and  thirty-five  who  have  borne  children,  as  small, 
ovoid,  firm  but  elastic,  distinctly  circumscribed  and  movable 
growths  in  the  breast,  with  a  nodular  or  slightly  bossed  surface. 
They  are  of  very  slow  growth,  do  not  cause  retraction  of  the 
nipple  or  enlargement  of  the  axillary  glands,  and  do  not  return  if 
completely  removed.     Enucleation  is  the  treafmenf. 

Adeno- FIBROMATA  are  of  frequent  occurrence.  They  consist  of 
fibrous  and  adenomatous  tissue,  and  are  siyXedi  fibromata  by  those 
pathologists  who  regard  the  gland-tissue  as  merely  the  remains  of 
the  normal  breast-tissue  surrounded  by  the  new  growth.  They 
occur  as  firm,  circumscribed,  slow- growing  and  distinctly  encap- 
suled  tumors  in  the  substance  of  the  breast,  and  on  section  appear 
lobulated  and  of  a  pinkish- white  color,  and  do  not  yield  a  juice  on 
scraping. 

Sigtis. — They  usually  occur  in  the  breast  of  young  and  healthy 
women  as  freely  movable,  firm,  ovoid,  slightly  nodular,  generally 
painless  growths,  and  are  often  indistinguishable  without  puncture 
from  a  tense  cyst.  From  carcinoma  and  sarcoma  they  may  be 
diagnosed  by  the  age  of  the  patient,  their  slow  growth,  well  de- 
fined outline,  non-retraction  of  the  nipple,  non-adherence  of  the 
skin,  and  the  absence  of  glandular  enlargement.  From  pure  ade- 
noma, adeno-sarcoma,  and  adeno-myxoma,  it  may  be  impossible 
to  distinguish  them  before  removal.  Enucleation  is  the  only 
effective  treainient. 

Adeno-sarcomata  differ  from  the  adeno-fibromata  in  that  in 
place  of  an  increase  of  fibrous  tissue  around  the  acini  and  ducts 
various  kinds  of  sarcomatous  elements  are  found  mixed  with  more 
or  less  mature  fibrous  or  myxomatous  tissue  ;  they  often  contain 
cysts.  Hence  the  terms  adeno-fibro-sarcoma,  adeno-myxo-sar- 
coma,  adeno-cysto-sarcoma,  fibro-cysto-sarcoma,  etc.,  which  have 
been  applied  to  them.  They  occur  as  circumscribed  growths  in 
the  breast,  resembling  the  adeno-fibromata,  from  which  it  is  often 
impossible  to  distinguish  them  without  a  microscopic  examina- 
tion. 


764  DISEASES   OF   REGIONS. 

Tlie  signs  vary  according  to  the  amount  of  sarcoma-elements 
the  growth  contains.  Thus,  when  this  is  small  they  approach  in 
their  clinical  character  and  behavior  the  adeno-fibromata.  On 
the  other  hand,  when  sarcoma-elements  abound,  they  may  grow 
rapidly,  and  behave  like  the  pure  sarcomata.  Frequently  they 
grow  slowly  for  many  years  and  then  suddenly  rapidly  increase  in 
size  as  the  patient  approaches  the  middle  period  of  life.  When 
occurring  between  the  ages  of  thirty  and  forty  they  often  grow 
rapidly  from  the  first. 

Treatment. — The  slow-growing  and  more  fibrous  forms  may  be 
enucleated,  but  if  in  proceeding  to  do  this  the  growth  is  found  to 
be  soft  and  succulent,  the  whole  breast  should  be  excised,  an 
operation  that  should  invariably  be  undertaken  when  the  tumor 
has  grown  rapidly. 

Pure  sarcomata. — All  forms  of  sarcoma  mixed  with  fibrous  and 
adenomatous  elements  may  occur  in  the  breast,  the  large  spindle- 
celled  variety  being  the  most  common.  Sarcomata  are  most  fre- 
quent between  the  ages  of  twenty  and  thirty-five.  They  begin  in 
the  periacinous  and  peritubular  connective  tissue,  and  at  first  are 
always  encapsuled,  but  later  they  infiltrate  the  surrounding  parts 
and  may  perforate  the  skin  and  fungate.  Their  malignancy  de- 
pends upon  their  structure,  the  round-celled  and  large-spindle- 
celled  being  highly  malignant,  the  small-spindle-celled  much  less 
so ;  indeed  the  latter  may  recur  again  and  again  iii  situ  before 
finally  becoming  disseminated,  or  its  tendency  to  recurrence  may 
completely  wear  itself  out.  The  small-spindle-celled  is  usually 
firm  like  the  adeno-sarcomata,  and  on  section  greyish-white, 
smooth  and  succulent.  The  round-celled  and  large-spindle-celled 
are  soft  and  elastic  owing  to  their  richness  in  cells  and  blood- 
vessels and  their  scanty  amount  of  intercellular  substance.  On 
section  they  appear  of  a  pinkish-white  color,  often  blotched  with 
blood,  while  cysts  from  h?emorrhages  and  mucoid  softening  some- 
times occur  in  them. 

Signs. — The  small-spindle-celled  sarcoma  can  hardly  be  diag- 
nosed before  removal  from  the  adeno-fibroma  and  adeno-sarcoma. 
The  large-spindle-celled  and  round-celled  varieties  form  smooth 
elastic  tumors,  oval  or  rounded  in  shape,  and  are  lobed  or  bossed 
when  cystic ;  whilst  the  veins  of  the  breast  are  often  enlarged  and 
tortuous.  They  grow  rapidly,  and  may  perforate  the  skin  and 
protrude  as  a  fungus;  but  unUke  carcinoma,  they  do  not  infiltrate 
the  skin  or  cause  retraction  of  the  nipple,  and  the  glands  are  not 
usually  enlarged.  The  tumor,  moreover,  is  commonly  larger  than 
scirrhus,  and  the  patient's  age  below  that  at  which  carcinoma  is 
usually  met  with. 

The  only  effectual  treatment  is  the  removal  of  the  whole  breast. 


ADENO-CYSTOMATA. 


765 


Cystic   adenoma   of  the  breast.      (St.    Bartholo- 
mew's Hospital  Museum.) 


If  there  is  any  doubt  whether  the  tumor  is  an  adeno-fibroma  or  a 
sarcoma,  it  is  better  to  have  the  consent  of  the  patient  before  the 
operation  for  the  removal  of  the  whole  breast,  should  the  tumor 
when  cut  into  appear  to  have  malignant  characters. 

Adeno-cvstomata,  cysto -sarcomata,  sero-cystic  sarcomata,  and 
glandular  proliferating  cysts,  are  terms  apphed  to  tumors  in  the 
breast  in  which  the  growth  in  the  periacinous  connective  tissue 
projects  into  the  interior  of  dilated  acini  and  ducts  in  the  form  of 
papillary  or  cauliflower-like  masses.  The  periacinous  growth, 
which  may  consist  of  fibrous 

tissue,  spindle  or  round  cells,  J^'^-  363. 

or  of  a  mixture  of  all  these, 
protrudes  the  wall  of  the  di- 
lated acinus  or  duct  in  front 
of  it,  but  does  not  penetrate 
the  epithehal  lining,  and  may 
ultimately  fill  the  whole 
acinus,  which  is  thus  con- 
verted into  a  mere  sHt- 
like  space  lined  with  epi- 
thelium. On  section  the 
tumor  may  present  one  or 
more  larger  cysts,  containing 
variously-shaped  cauliflower-like  growths  sprouting  from  their 
walls.  Or  it  may  appear  completely  solid  from  the  cysts  having 
been  entirely  filled  with  intra-cystic  growths ;  on  dissection,  how- 
ever, the  spaces  between  the  growths  and  the  cyst-walls  can  al- 
ways be  demonstrated  (Fig.  365).  When  the  growth,  which  is 
at  first  encapsuled,  attains  some  size,  the  skin  may  give  way  and 
the  growth  protrude  in  the  form  of  a  fungus.  The  skin,  however, 
does  not  become  infiltrated  as  in  carcinoma. 

S/g//s. — They  generally  occur  in  women  between  the  ages  of 
thirty  and  thirty-five,  as  distinctly  defined,  lobulated.  usually  pain- 
less growths,  hard  in  some  places  and  soft  and  fluctuating  in 
others,  and  often  of  large  size.  The  veins  over  them  are  enlarged, 
but  the  skin  is  not  adherent,  the  nipple  is  not  retracted,  and  the 
glands  as  a  rule  are  not  aff'ected.  They  commonly  grow  slowly, 
but  at  times  rapidly,  and  seldom  or  never  become  disseminated. 
Their  chief  distinguishing  characteristic  is  the  presence  of  one  or 
more  prominent  fluctuating  cysts  in  the  tumor.  Should  a  fungus 
protrude,  it  may  be  distinguished  from  carcinoma  by  the  non-im- 
plication of  the  skin  around,  non-adherence  of  the  growth  to  the 
side  of  the  chest,  and  the  absence  of  the  other  signs  of  carcinoma 
above  pointed  out.  Removal  of  the  breast  is  the  proper  ^rca/- 
ment. 


766  DISEASES   OF   REGIONS. 

Cysts. — The  cysts  met  with  most  frequently  in  the  breast  are 
the  serous  cysts,  and  certain  of  the  retention  cysts.  Serous  cysts 
are  formed  in  the  breast,  as  in  other  situations,  by  the  distension 
with  fluid  of  the  lymphatic  spaces  of  the  connective  tissue  (see 
Serous  Cvsfs).  The  retention  cysts  that  occur  in  the  breast  may 
be  divided  into  the  galactoceks,  which  are  produced  by  the  dila- 
tation of  the  galactophorous  ducts,  and  the  glandular  cysts,  due 
to  the  distension  of  the  smaller  ducts  and  acini.  The  former 
contain  a  milk-like  fluid,  or  when,  as  occasionally  happens,  the 
watery  parts  have  been  absorbed,  an  inspissated  caseous  material. 
The  glandular  contain  a  yellowish  or  brownish-yellow  mucoid 
fluid,  sometimes  blood-stained,  and  at  times  intracystic  papillary 
growths,  formed  by  the  ingrowing  of  the  cyst  walls.  When  they 
occur  in  elderly  people  they  are  spoken  of  as  involution  cysts. 
Their  frequency  in  chronic  lobular  inflammation  of  the  breast  has 
already  been  alluded  to. 

Signs. — Cysts  in  the  breast  form  painless,  tense,  or  semifluctua- 
ting,  smooth,  rounded  tumors,  evidently  connected  with  the  breast 
tissue.  Serous  cysts  may  occur  in  any  part  of  the  breast.  They 
are  often  very  tense  and  hard,  and  breasts  with  such  in  them 
have  been  removed  for  cancer.  Hence  the  valuable  rule  of  mak- 
ing a  preliminary  incision  if  in  doubt  as  to  the  nature  of  the 
tumor.  The  galactoceles  occur  during  lactation  ;  they  are  situated 
near  the  nipple,  from  which  a  milk-like  fluid  may  sometimes  be 
squeezed  out  on  pressing  the  cyst.  They  are  soft  and  fluctuating, 
and  usually  single,  form  quickly,  and  may  attain  a  large  size. 
Glandular  cysts  occur  chiefly  in  women  of  from  thirty-five  to 
fifty.  They  are  tense  and  painless,  form  slowly,  may  occur  singly, 
but  are  often  multiple.  A  sanious  fluid  sometimes  escapes  from 
the  nipple  if  the  cyst  contains  a  papillary  growth. 

Treatment. — Simple  serous  cysts  may  be  laid  freely  open  and 
allowed  to  granulate  from  the  bottom,  or  better  be  dissected  out. 
Galactoceles,  with  semi-solid  contents,  may  also  be  laid  freely 
open  and  their  contents  squeezed  out.  Glandular  cysts,  when 
nmnerous,  call  for  the  excision  of  the  affected  lobule,  or  if  the 
whole  breast  is  affected  and  they  contain  proliferating  growths, 
excision  of  the  entire  gland.  Involution  cysts  require  no  treat- 
ment. 

Carcinoma  of  the  breast  is  nearly  always  of  the  acinous  form, 
of  which  both  varieties,  the  hard  (^scirrhous)  and  the  soft  {medul- 
lary), are  met  with.  The  hard  variety,  however,  is  by  far  the 
most  common.  The  general  and  microscopical  characters  of  car- 
cinoma have  already  been  given  under  tumors.  Here  only  the 
special  characters  which  it  presents  when  occurring  in  the  breast 
will  be  referred  to. 


SCIRRHOUS   CARCINOMA. 


767 


Scirrhous  carcinoma. — Pathology. — Scirrhus  of  the  breast  gen- 
erally appears  as  an  indurated;  nodular,  non-encapsuled,  tuberous 
mass,  of  moderate  dimensions,  with  long  processes  extending  in 
various  directions  in  the  gland-substance  and  the  fatty  tissue 
around,  and  later,  invoh'ing  the  skin  and  subjacent  pectoral 
muscle.  On  section  (Fig.  366)  the  tumor  gives  a  characteristic 
creaking  sensation  to  the  knife,  and  the  cut  surface  appears 
slightly  concave  from  the  contraction  and  shrinking  of  its  fibrous 
stroma  thus  set  free  from  the  traction  of  surrounding  tissues.  It 
is  of  a  hard  resisting  consistency,  of  a  uniform  close  texture, 
semi-translucent,  of  a  greyish-white  color  often  tinged  with  pink, 
and  has  been  hkened  to  the  section  of  a  potato  or  unripe  pear. 
Sometimes  it  is  intersected  in  every  direction  by  short  wavy  glis- 

FlG.  366. 


Scirrhous  carcinoma  of  the  breast.     (St.  Bartholomew's  Hospital  Museum.) 


tening  white  fibres,  with  here  and  there  yellow  dots  and  streaks 
due  to  section  of  the  epithelial  cokunns  which  have  undergone 
fatty  degeneration ;  whilst  in  other  places,  little  masses  of  the 
surrounding  fatty  tissue  and  of  muscle  are  seen  enclosed  by  the 
processes  of  the  growth  ;  and  patches  of  caseous-looking  material 
or  white  creamy  fluid,  due  to  the  growth  having  surrounded  some 
of  the  ducts  which  have  become  only  partially  obliterated,  may  be 
scattered  through  its  substance.  The  section  on  scraping  yields 
a  juice  containing  cells,  free  nuclei,  and  granular  material. 

Signs. — Scirrhous  carcinoma  generally  begins  as  a  small  hard 
lump  in  the  substance  of  the  breast ;  it  grows  slowly  at  fir.^t,  after- 
wards more  rapidly,  and  then  involves  the  skin  and  pectoral 
muscle  ;  finally,  the  skin  gives  way,  and  a  foul  ulcer  is  produced. 


768  DISEASES   OF   REGIONS. 

In  the  meantime,  the  lymphatic  glands  in  the  axilla  become  in- 
volved, and  as  they  increase  in  size  press  upon  the  axillary  vein 
and  brachial  plexus  of  nerves,  producing  oedema  of  the  arm  and 
intense  neuralgic  pain.  Later  the  cancer  becomes  disseminated 
through  the  internal  organs  and  tissues  of  the  body.  The  health, 
which  on  the  first  appearance  of  the  growth  is  generally  good, 
now  gives  way,  the  skin  becomes  sallow  and  earthy  in  appear- 
ance, the  patient  wasted,  and  cancerous  cachexia  is  said  to  be 
present.  The  foul  and  profuse  discharge  from  the  ulcer,  the  in- 
tense pain,  the  mental  suffering,  and  the  implication  of  internal 
organs,  lead  to  exhaustion,  and  death  soon  steps  in  to  put  an  end 
to  the  patient's  misery.  Such  is  the  brief  outline  of  the  course  of 
the  disease  when  not  subjected  to  surgical  interference.  Let  us 
now  study  the  characters  of  the  tumor  as  presented  in  a  typical 
case.  It  is  usually  situated  in  the  upper  and  outer  quadrant  of 
the  breast,  or  just  below  the  nipple.  Its  surface  is  hard  and  ir- 
regular, its  margins  ill- defined.  The  skin  at  first,  when  gendy 
pinched  up  between  the  finger  and  thumb,  shows  a  slight  dimp- 
ling, and  later  appears  distinctly  puckered  and  unmistakably  ad- 
herent to  the  growth.  In  the  earlier  stages  the  tumor  glides 
freely  over  the  pectoral  muscle  ;  later  a  slight  resistance  is  felt  on 
moving  it  from  side  to  side  ;  whilst  finally  it  becomes  firmly  fixed 
to  the  walls  of  the  chest.  The  nipple,  when  the  growth  is  behind 
it,  is  retracted,  in  consequence  of  the  traction  which  is  made  by 
the  carcinoma  upon  the  lacteal  ducts  (Fig.  366)  ;  but  when  the 
growth  is  situated  in  the  circumference  of  the  breast,  there  may 
be  no  retraction,  or  the  retraction  may  occur  only  on  one  side ; 
whilst  when  the  cancer  begins  as  an  infiltration  of  the  nipple 
itself,  the  latter  will  be  harder  and  more  prominent  than  natural. 
On  raising  the  arm  and  drawing  the  finger-tips  transversely 
across  the  inner  side  of  the  axilla,  a  hard  cord  or  cords — infil- 
trated lymphatic  vessels — may  often  be  felt  extending  from  the 
tumor  into  the  axilla,  while  in  the  space  itself  large  glands  will  be 
discovered  if  the  case  is  su  Anciently  advanced.  The  glands  are  at 
first  soft,  single  and  distinct,  later,  hard  and  matted  together, 
forming  an  indurated  irregular  mass  which  is  often  adherent  to 
the  chest-walls  and  in  advanced  cases  extends  as  high  as  can  be 
felt  beneath  the  clavicle.  In  the  supraclavicular  space  the  en- 
larged glands  may  sometimes  be  detected,  first  as  a  mere  fulness, 
subsecjuently  as  distinct  swellings.  After  the  skin  over  the  tumor 
has  given  way,  an  ulcer  with  sinuous,  irregular,  everted,  and  in- 
durated edges,  and  a  foul,  cavernous,  irregular,  and  indurated 
base  is  formed,  from  which  is  exuded  a  foul-smelling  and  sanious 
discharge.  The  skin  around  is  indurated  from  infiltration  with 
the  growth  ;  or  -distinct,  circumscribed,  hard  nodules  of  carci- 
noma are  scattered  here  and  there  through  it. 


SCIRRHOUS   CARCINOMA.  769 

Diagnosis. — When  the  above  signs  are  present  there  is  no  diffi- 
culty in  pronouncing  as  to  the  nature  of  the  disease.  In  the 
earUer  stages,  however,  whilst  the  tumor  is  still  small  and  has  not 
yet  become  adherent  to  the  skin  or  to  the  pectoral  muscle, 
where  the  breast  is  large  and  there  is  no  retraction  of  the  nipple, 
and  as  yet  there  is  no  enlargement  of  the  axillary  glands,  the  di- 
agnosis from  an  innocent  tumor,  a  tense  cyst,  or  lobular  inflam- 
mation will  be,  to  say  the  least,  difficult.  The  age  of  the  patient, 
the  rate  of  growth,  and  the  history  of  the  case,  must  then  to  a 
great  extent  be  relied  on  for  distinguishing  it.  But  where  the 
patient,  as  is  occasionally  the  case,  is  young,  the  diagnosis  may 
then  be  impossible  without  making  an  incision  into  the  growth,  a 
proceeding  which,  under  such  circumstances,  after  the  difficulty 
has  been  explained  to  the  patient,  is  not  only  justifiable,  but  im- 
peratively called  for. 

Rarer  fo7-ms  of  scirrhus  in  the  breast  are  occasionally  met  with. 
Thus — I.  The  cancer  may  begin  as  a  general  infiltration  of  the 
entire  gland,  when  its  course  is  usually  very  rapid.  2.  It  may 
chiefly  affect  the  lymphatics  of  the  skin,  the  whole  side  of  the 
chest  in  such  a  case  becoming  infiltrated,  hard,  brawny  and  leath- 
ery in  consistency,  a  condition  known  as  "hide-bound."  3.  It 
may  begin  as  an  infiltration  of  the  nipple,  or  may  be  engrafted 
upon  chronic  eczema  around  the  nipple.  4.  In  elderly  w^omen  it 
may  run  a  very  chronic  course,  often  remaining  stationary,  if  not 
interfered  with,  for  many  years  (fibrous  or  chronic  cancer).  5. 
In  very  exceptional  instances,  the  carcinomatous  mass  has  appa- 
rently undergone  complete  atrophy,  even,  it  is  said,  after  ulcera- 
tion has  occurred,  and  a  spontaneous  cure  has  thus  been  brought 
about. 

Treatment. — In  the  breast,  as  elsewhere,  the  only  hope  of  cure 
lies  in  the  early  and  complete  extirpation  of  the  carcinoma.  Un- 
less, therefore,  the  Surgeon  is  consulted  before  the  skin,  pectoral 
muscle  and  lymphatic  glands  are  more  than  slightly  involved,  he 
can  hold  out  but  little  prospect  that  the  disease  will  not  return, 
and  return  shortly,  or  that  life  will  be  materially,  if  at  all,  prolonged 
by  an  operation.  Under  such  circumstances,  therefore,  there  are 
some  Surgeons  who  hold  that  an  operation  with  the  disease  thus 
advanced  ought  not  to  be  undertaken,  as  it  can  only  bring  dis- 
credit on  surgery,  and  may  possibly  prevent  other  patients  seek- 
ing advice  whilst  there  is  yet  a  probability  that  a  free  and  com- 
plete removal  of  the  breast  and  axillary  glands  may  eradicate  the 
disease.  While  admitting  that  this  may  be  true,  we  must  not  lose 
sight  of  the  fact  that  even  although  the  growth  may  soon  recur 
either  in  the  cicatrix  or  glands,  or  in  internal  organs,  and  although 
life  may  not  be  prolonged,  still  removal  of  the  growth  may  rid  the 


770  DISEASES   OF   REGIONS. 

patient  of  a  foul  and  loathsome  disease  and  often  of  great  pain,  at 
any  rate  for  a  time,  and  death  may  occur  in  a  less  distressing  way 
from  dissemination  of  the  carcinoma  in  internal  organs.  In  the 
meanwhile  the  patient's  mind  will  be  relieved,  even  if  she  is  not 
buoyed  up  with  the  hope  that  there  may  still  be  a  chance  of  a 
non-return.  Regarding  the  question  of  operation,  therefore,  it 
may  be  briefly  said  that — i.  Where  the  skin  is  not  involved,  or  to 
a  very  slight  extent,  the  tumor  not  adherent  to  the  pectoral  mus- 
cle, and  the  glands  are  not  felt  enlarged,  or  if  enlarged  are  not 
adherent  to  the  chest  wall,  free  removal  of  the  breast,  and,  in  the 
last  case,  clearing  out  the  axilla,  is  imperatively  called  for.  2. 
Where,  on  the  other  hand,  the  skin  is  extensively  infiltrated,  the 
tumor  is  firmly  adherent  to  the  pectoral  muscle,  the  glands  are 
enlarged,  hard,  and  adherent  to  the  side  of  the  chest,  enlarged 
glands  can  also  be  felt  above  the  clavicle,  and  perhai^s  have  al- 
ready caused  oadema  of  the  arm,  marked  cachexia  is  present,  and 
there  is  evidence  of  dissemination  of  the  carcinoma  in  other  or- 
gans and  tissues — then  no  oi)eration  should  be  performed.  In 
cases  such  as  the  above,  theie  can  belittle  question  as  to  the  pro- 
priety of  operating  or  not  operating.  But  there  is  a  large  class 
of  intermediate  cases  in  which  some  Surgeons  would,  and  some 
would  not,  operate.  Much  will  then  depend  upon  the  presence 
or  absence  of  pain,  the  age  of  the  patient,  etc.,  and  each  case 
must  be  judged  on  its  own  merits.  When  too  far  advanced  to 
permit  of  removal,  all  that  can  be  done  is  to  relieve  pain  and  pro- 
cure sleep  by  opium  or  morphia,  and  support  the  strength  by  a 
liberal  diet  and  stimulants.  Should  an  ulcer  have  formed  it  may 
in  some  cases  be  treated  with  caustics,  as  Eougard's  paste  or  pyok- 
tanin,  or  dusted  with  iodoform  or  charcoal  to  control  the  foetor. 

MEDur.LARY  CARCINOMA  is  much  less  common  in  the  breast 
than  the  scirrhous  form,  and  generally  appears  at  an  earlier  age. 
It  occurs  as  a  soft,  non-encapsuled,  compact,  white  or  blood- 
stained, brain-like  mass  infiltrating  the  gland  and  surrounding 
tissues.  Its  growth  is  much  more  rapid  than  the  scirrhous  variety, 
and  it  sooner  involves  the  skin,  pectoral  muscles,  and  axillary 
glands,  and  rapidly  becomes  disseminated  through  internal  organs. 
Early  and  free  removal  of  the  whole  breast,  and  of  any  glands  in 
the  axilla  that  may  be  felt  enlarged,  is  the  proper  treatment. 

Other  varieties  of  carcinoma  in  the  breast,  as  the  so-called 
villous  or  duct  cancers,  and  the  colloid,  require  only  a  brief  notice. 

Duct  carcinoma  occurs  as  one  or  more  rounded  masses  lying 
in  the  breast  tissue  not  far  from  the  nipple.  On  section  these 
masses  appear  as  red,  encysted  and  definite  tumors  (Fig.  367). 
Microscopically  they  consist  of  cysts,  often  containing  blood,  and 
into  which  papillary  growths,  covered   by  columnar   epithelium, 


EXCISION    OF    THE    BREAST. 


771 


sprout.  The  growths  have  an  alveolar  structure,  and  closely 
resemble,  especially  when  the  disease  has  recurred,  ordinary 
encephaloid  carcinoma. 

Sigf2s. — The  nipple  is  not,  as  a  rule,  retracted,  but  there  is  usu- 
ally a  history  of  a  discharge  of  blood  from  it,  often  before  a  tumor 
is  noticed.  In  the  specimen  of  which  Fig.  367  is  a  drawing, 
there  was  very  slight  retraction  of  the  nipple.  The  skin  is  not 
infiltrated,  the  axillary  glands  are  not  enlarged,  and  secondary 
deposits  are  very  rare.  The  tumor  is  firm  and  elastic,  and  may 
contain  one  or  more  cysts.  It  usually  occurs  in  middle  age,  is  of 
slow  growth,  and  not  accompanied  as  a  rule  by  pain.  The  /rea^- 
ment  consists  in  amputation  of  the  whole  breast.  If  this  is  done, 
no  further  trouble  usually  occurs. 

Colloid  carcinoma  of  the  breast  is  very  rare.  Its  structure  is 
like  that  of  scirrhus  or  encephaloid  cancer,  but  here  and  there 
large  epithelial  cell-masses  have  undergone  colloid  degeneration. 
It  is  of  slower  growth,  and  less  frequently  affects  the  glands,  than 

Fig.  367. 


Section  of  a  duct  carcinoma  of  the  heart.  The  tumor  has  well-defined  edges,  and  is  composed 
of  a  numbi-T  of  cysts  containing  growths  and  broken-down  blood.  (St.  Bartholomew's 
Hospital  Museum,  No.  3,  186,  i). 

either  scirrhus  or  encephaloid,  and  has  a  less  tendency  to  recur 
after  removal.  The  prospective  length  of  life  is  said  to  be  three 
or  four  times  that  of  ordinary  scirrhus. 

Excision  of  the  breast. — The  arm  being  held  out  from  the 
side  by  an  assistant  so  as  to  put  the  pectoral  muscle  on  the  stretch 
and  well  expose  the  axilla,  an  elliptical  incision  should  be  made 
below  and  another  above  the  nipple,  cutting  widely  of  any  adherent 
or  infiltrated  skm.  The  skin  above  and  below  should  now  be  re- 
flected from  the  breast,  and  the  latter  dissected  off  the  pectoral 
muscle,  taking  care  to  lemove  the  pectoral  fascia  and  any  portion 
of  the  muscle  that  appears  affected  with  the  disease.  Should  any 
gland  be  felt  in  the  axilla,  the  incision  should  be  prolonged  in  an 
upward  and  outward  direction,  the  axillary  fascia  opened  by  the 
scalpel,  and  all  the  glands  that  can  be  felt  carefully  dissected  out  or 
enucleated,  in  part  by  the  fingers,  and  in  part  by  the  handle  of  the 


772 


DISEASES    OF   REGIONS. 


scalpel,  care  being  taken  not  to  injure  the  axillary  vessels  or  large 
nerve-cords,  both  of  which  are  situated  at  the  upper  and  outer 
part  of  the  space.  The  skin  should  now  be  drawn  together  by 
sutures,  a  drainage  tube  having  been  placed  in  the  deeper  part  of 
the  wound.  Where  the  skin  cannot  be  made  to  cover  in  the 
wound,  the  flaps  should  be  drawn  as  much  together  as  possible  by 
stout  silver  sutures,  and  the  remainder  of  the  wound  left  to  granu- 
late. The  arm  should  be  secured  to  the  side  with  the  forearm 
and  hand  across  the  chest.  Some  Surgeons,  with  a  view  to  the 
more  complete  removal  of  glands,  divide  the  pectoral  muscles 
or  even  cut  the  pectoral  muscles  away.  This  procedure  is  fol- 
lowed by  so  much  contraction  and  subsequent  interference  with 
the  movement  of  the  arm,  that  I  do  not  advise  it  save  under  ex- 
ceptional conditions,  as  when  the  pectoral  is  infiltrated  or  glands 
cannot  be  otherwise  reached.  It  does  not  ensure  the  complete 
removal  of  the  disease,  since  the  mediastinal  glands  may  be  affected. 

DEFORMITIES   OF    THE    NECK,    KNEES    AND    FEET. 

Wry-neck  or  torticollis  is  a  distortion  chiefly  dependent  upon 
contraction  of  the  sterno-mastoid  muscle.  It  may  be  congenital 
or  acquired. 

Causes. — -The  congenital  form  is  attributed  to — i,  spastic  con- 
traction of  the  sterno-mastoid  muscles  due  to  disease  of  the 
nervous  system  ;  2,  malposition  in  utcro ;  or,  3,  injury  at  birth,  as, 
for  example,  rupture  of  the  sterno-mastoid  in  a  breech  presenta- 
tion. The  acquired f 01-711  is  due  to — i,  the  head  having  been  held 
for  a  long  time  in  the  distorted  position  as  a  consequence  of  stiff" 
neck  following  cold,  rheumatism,  injury,or  in- 
FiG.  368.  flamed  cervical  glands  ;  2,  hysteria  :  or  3,  spasm 

set  up  by  irritation  of  the  spinal  accessory 
nerve  consequent  upon  central  nerve  trouble. 
Signs. — The  head,  supposing  the  right 
sterno-mastoid  to  be  affected,  is  drawn  for- 
wards and  towards  the  right  shoulder  and 
also  rotated,  so  that  the  chin  points  to  the 
left.  The  right  mastoid  is  ])rominent,  the 
right  side  of  the  neck  concave,  and  the  left 
convex.  In  long-standing  cases  some  lateral 
curvature  of  the  dorsal  sj^ine  is  generally  ac- 
(]nired.  The  congenital  form  may  be  distin- 
guished from  the  spasmodic  not  only  by  its 
history,  but  by  the  sterno-mastoid  becoming 
tense  in  the  former,  and  yielding  in  the  latter, 
Wry-neck  .ipparatus.  on  attempting  to  Straighten  the  head.  The 
hysterical  variety  will  be  known  by  the  pres- 
ence of  other  signs  of  hysteria. 


KNOCK- KNEE    OR    GENU    VALGUM.  773 

Treatment. — In  congenital  wry-neck,  unless  the  patient  is  treated 
by  position  while  still  an  infant,  division  of  the  sterno-mastoid  is 
generally  required,  followed  by  a  course  of  systematic  exercises  in 
the  slighter  cases,  and  the  use  of  some  such  instrument  as  that 
shown  in  Fig.  368,  in  the  most  severe.  The  sterno-mastoid  is 
best  divided  immediately  above  the  clavicle,  as  here  it  is  furthest 
removed  from  the  important  structures  that  lie  beneath  it.  A 
puncture  should  be  made  at  the  inner  side  of  the  tendon,  a  director 
passed  behind  it,  and  the  division  made  towards  the  skin  with  a 
blunt-pointed  tenotome.  The  tense  bands  of  contracted  cervical 
fascia  which  now  start  forward  will  yield  to  stretching ;  it  is  not 
safe  to  divide  them.  The  head  should  be  straightened  and  thus 
held  by  a  bandage  and  sand-bags.  The  puncture  should  be  given 
three  or  four  days  to  heal  before  the  exercises  are  begun  or  the 
instrument  is  applied.  Some  advise  the  division  of  the  muscle 
about  the  middle,  on  the  plea  that  such  is  a  more  safe  procedure  ; 
whilst  others  again  recommend  the  division  of  the  tendon  by  open 
incision,  as  in  this  way  the  danger  of  puncturing  and  admitting 
air  into  a  vein  is  avoided.  If  the  subcutaneous  division,  however, 
is  carefully  done  in  the  manner  here  advised,  I  do  not  believe 
there  need  be  any  fear  of  air  entering  the  veins.  I  have  now  per- 
formed this  little  operation  many  times,  and  have  never  exper- 
ienced any  difficulty  or  trouble.  At  the  same  time  it  is  only  right 
to  state  that  sudden  death  has  occurred  in  the  hands  of  some  ex- 
cellent Surgeons,  and  others  have  met  with  alarming  symptoms. 
In  spasmodic  cases  conium,  Indian  hemp,  bromide  of  potassium, 
etc.,  may  be  tried.  These  failing,  the  spinal  accessory  nerve  may 
be  stretched  just  above  the  spot  where  it  enters  the  sterno-mastoid. 
In  very  intractable  cases  a  piece  of  the  nerve  may  be  excised, 
and  if  the  posterior  cervical  muscles  are  also  involved  in  the 
spasm,  excision  of  portions  of  the  posterior  division  of  the  first 
four  cervical  nerves  may  be  simultaneously  or  subsequently  under- 
taken. Tenotomy  of  the  sterno-mastoid  should  in  these  and  in 
hysterical  cases  on  no  account  be  done.  In  the  latter,  hysterical 
remedies  should  of  course  be  used. 

Knock-knee  or  genu  valgum  is  a  deformity  in  which,  when  the 
knees  are  placed  together  in  the  extended  position  with  the 
patellae  looking  directly  forwards,  the  legs  diverge.  One  or  both 
knees  may  be  affected,  or  there  may  be  genu  valgum  on  one  side 
and  genu  varum  on  the  other. 

Cause. — Knock-knee  is  generally  the  result  either  of  rickets, 
when  it  occurs  between  the  second  and  the  seventh  year  ;  or  of 
carrying  heavy  weights,  long  standing  and  the  like,  when  it  is 
iTfost  common  is  growing,  underfed  and  overworked  lads  and  girls 
from  fourteen  to  eighteen.     The  deformity  is  variously  believed 


774  DISEASES   OF   REGIONS. 

to  depend  on  :  i,  an  overgrowth  of  the  internal  condyle  of  the 
femur,  and  a  corresponding  uprising  of  the  inner  tuberosity  of 
the  tibia;  2,  the  relaxation  of  the  internal  lateral  ligament ;  or  3, 
the  contraction  of  the  biceps  tendon.  In  the  majority  of  cases 
the  osseous  lesion  is  certainly  present,  and  I  have  no  doubt  in  my 
own  mind  that  it  is  upon  this  that  the  deformity  in  rickety  cases 
usually  depends,  though  I  admit  that  in  some  of  those  rapid  cases 
induced  by  excessive  weight-bearing  in  weakly  lads,  a  relaxation  of 
the  ligaments  may  be  the  principal  factor.  The  contraction  of 
the  biceps  tendon  when  present  I  regard  as  the  result,  and  not 
as  the  cause  of  the  affection.  Treatment. — In  slight  rickety 
cases,  keeping  the  child  entirely  off  its  legs,  the  application  of 
splints,  and  the  internal  use  of  appropriate  remedies,  will  gener- 
ally effect  a  cure.  In  confirmed  cases,  and  in  older  patients, 
however,  little  must  be  expected  from  splints  or  instruments.  By 
their  use  the  limb  can  no  doubt  be  straightened,  but  only  at  the 
expense  of  stretching  the  external  lateral  ligament,  the  legs  being 
rendered  flail-like,  and  the  patient  being  unable  to  walk  or  even 
stand  without  his  irons.  For  such,  some  form  of  osteoclasia  or 
Osteotomy  is  usually  required. 

Osteoclasia  consists  in  breaking  the  bone 
Fig.  369.  either  with   the  hands  or  with  the  osteoclast. 

Manual  osteoclasia  is  seldom  employed  except 
for  the  correction  of  rickety  bow-legs  or  knock- 
knee    in  young  subjects  when   the  bones  are 
moderately  soft.     For    fracturing   larger    and 
^      stronger  bones  the  osteoclast  is  required.    The 
3      limb  is  properly  adjusted  between  the  arms  of 
c      the  instrument  and  the  force  applied  by  means 
of  a  screw  in  Grattan's  osteoclast,  or  by  levers 
in  that  of  Thomas. 

Osteotomy  is  usually  done  by  Macewen's  or 
Reeves'  modified  Ogston's  method,  i.  Mace- 
wen^s  operation  consists  in  chiselling  through 
the  femur  just  above  the  epiphysis,  but  leaving 
the  posterior  surface,  which  is  in  contact  with 
the  popliteal  artery,  intact,  and  snapping  this 
A   line  of  section  in      across  by  forciblv  bending  the  bone.     2.  In 

Macewen  s  ;      1>,   in  J  ■  /-,-., 

Oeston's;  and  c,  in  Recvcs'  modification  of  Oi^stoii  s  Operation,  the 
stonrope°S"^'  internal  condyle  is  fir'st  loosened  with  a  chisel, 
and  then  made  to  ;:lide  uiiwards  on  the  shaft 
of  the  femur  by  .forcibly  straiiditening  the  leg.  The  chi.sel  is 
introduced  behind  the  synovial  meinbrane  and  shcnild  not  be 
driven  so  far  into  the  condyle  as  to  endang'T  the  opening  of  the 
joint.     The  line  of  incision  through  the  femur  in  these  operations 


TALIPES    OR    CLUB-FOOT.  775 

is  shown  in  Fig.  369.  The  incision  in  the  soft  tissues,  which  in 
either  operation  should  be  merely  long  enough  to  admit  the 
chisel,  may  in  each  be  made  vertically  two  fingers'  breadth 
above  the  patella,  and  midway  between  the  inner  edge  of  the 
rectus  and  the  tendon  of  the  adductor  magnus.  The  operations 
should  be  performed  antiseptically  and  the  limb  secured  to  a  long 
splint,  or  placed  in  Bavarian  plaster  splints  in  a  straight  position 
for  about  a  month,  and  subsequently  kept  in  an  ordinary  plaster 
case  for  six  weeks  to  two  months  till  sound  union  has  taken  place. 

Genu  varum,  or  bow-legs,  is  the  opposite  deformity  to  genu 
valgum,  and  what  has  been  said  of  the  latter  as  regards  pathology, 
treatment,  etc.,  will  apply  to  it  if  external  be  substituted  for  in- 
ternal in  the  phraseology.  It  is  frequently  associated  with  a  bow- 
ing of  the  shaft  of  the  tibia,  either  at  its  upper  or  its  lower  third, 
and  sometimes  with  a  bowing  of  the  femur. 

Genu  recurvatum  or  extrorsum  is  a  condition  of  over- exten- 
sion at  the  knee.  It  is  frequently  present  in  a  slight  degree  in 
cases  of  knock-knee.  It  sometimes  occurs  as  a  congenital  affection  ; 
the  hyper-extension  may  then  be  extreme,  the  feet  touching  the 
groins.  When  it  is  combined  with  knock-knee,  the  irons  for  the 
latter  affection  should  have  a  front  stop.  In  congenital  cases  di- 
vision of  the  quadriceps  may  be  necessary,  but  continual  attempts 
at  flexion  and  the  use  of  an  instrument  with  a  cog-wheel  at  the 
knee  will  usually  suffice. 

Talipes  or  club-foot  is  a  distorsion  in  which  the  relations  to  the 
tarsal  bones  to  each  other  and  to  the  bones  of  the  leg  are  variously 
altered,  and  the  bones  held  in  their  abnormal  position  by  alteration 
in  the  shape  of  the  bones  and  by  the  contraction  or  shortening  of 
certain  of  the  muscles,  ligaments,  and  fasciae  attached  to  the  foot. 

Cause. — Talipes  may  be  either  congenital  or  acquired. 

The  congenital  form  has  been  attributed  to — i,  spastic  muscu 
lar  contraction  induced  by  some  lesion  of  the  nerve-centres ;  2, 
malpositions  of  the  foetus  in  iitero  ;  3,  structural  alteration  in  the 
form  of  some  of  the  tarsal  bones.  The  supporters  of  the  first 
view  maintain  that  the  bones  are  drawn  into  their  abnormal  posi- 
tion by  muscular  contraction,  and  regard  any  alteration  in  the 
shape  of  the  bones  as  the  result  and  not  as  the  cause  of  their 
malposition  ;  whilst  those  who  uphold  the  second  and  third  views 
deny  that  spastic  contraction  occurs,  as  no  lesion  of  the  nerve- 
centres  has  been  found  to  account  for  it,  and  look  upon  the  con- 
traction of  the  muscles  as  merely  due  to  adaptive  shortening  con- 
sequent upon  the  altered  position  of  the  bones.  The  congenital 
variety  is  sometimes  hereditary,  very  occasionally  occurs  in  sev- 
eral members  of  the  same  family,  and  is  frequently  associated 
with  other  congenital  malformations,  as  spina  bifida,  meningocele, 


776 


DISEASES   OF   REGIONS. 


etc.  The  acquired  form  is  generally  the  result  of  infantile  paraly- 
sis, the  bones  then  either  being  drawn  into  their  abnormal  posi- 
tions by  the  contraction  of  the  muscles  antagonistic  to  those 
paralyzed,  or  falling  into  the  abnormal  positions  by  the  weight  of 
the  foot.  In  either  case  the  weight  of  the  body  in  standing  and 
walking  tends  more  and  more  to  confirm  this  faulty  position. 
Amongst  other  causes  may  be  mentioned  long  continuance  of  the 
foot  in  the  extended  position,  disease  of  the  ankle  or  tarsus, 
yielding  of  the  ligaments,  etc. 

Varieties. — There  are  five  principal  forms  of  club-foot : — Talipes 
equiniis,  varus,  calcaneus,  valgus,  and  cavus.  But  these  may  be 
variously  combined,  producing  compound  forms,  which  are  then 
called  equino-varus ,  equino-valgus ,  calcaneo-valgus,  etc. 

T.  Talipes  equimis  (Figs.  370,  371)  is  nearly  always  an  ac- 
quired affection,  and  generally  due  to  infantile  paralysis  of  the  an- 
terior or  extensor  muscles ;  as  a  congenital  affection  it  is  very 
rare.  I  have  only  seen  two  cases  during  the  twelve  years  I  have 
had  charge  of  the  orthopoedic  department  at  St.  Bartholomew's. 
The  heel  is  drawn  upwards  by  the  tendo  Achillis,  and  the  anterior 
part  of  the  foot  is  in  consequence  depressed  and  held  in  the  ex- 
tended position.  The  weight  of  the  body  is  thus  transmitted 
through  the  heads  of  the  metatarsal  bones,  which  together  with 
the  anterior  part  of  the  tarsus  are  bent  down- 
wards and  backwards  from  the  transverse  ^'^-  371- 
tarsal  joint  and  fixed  in  this  position  by  the 
adai)tive  shortening  of  the  plantar  fascia,  liga- 
ments and  muscles,  thus  rendering  the  sole  of 

Fig.  370. 


Cun^eniUL  Ace/ulrccL 

Talipes  cquinus.     (Bryant's  Surgery.) 


Talipes  equiniis,  with 
coin])lcte  paralysis  of 
the  iinlerior  muscles. 


the   foot   unnaturally  concave,  a  condition  known  as  pes  cavus. 
The  patient  walks  with  fatigue  and  lameness  on  the  balls  of  hi!> 


TALIPES    OR    CLUB-FOOT. 


777 


toes,  (Fig.  370),  and  if  both  feet  are  affected  he  may  be  unable 
to  walk  at  all.  When  the  extensor  muscles  of  the  toes  are  com- 
pletely paralyzed  the  toes  may  be  bent  under  as  shown  in  Fig. 
371,  and  the  patient  walks  on  the  dorsum  of  the  toes  or  even  on 
the  dorsum  of  the  foot.  Corns,  and  perhaps  ulcers,  are  then 
formed,  rendering  walking  exceedingly  painful  or  impossible.  In 
long-standing  cases,  in  consequence  of  the  contraction  being 
greater  on  the  inner  than  on  the  outer  side  of  the  sole,  an  inward 
twist  is  given  to  the  foot  {equino-varus).  At  times  the  tendo 
AchiUis  is  not  sufficiently  shortened  to  draw  up  the  heel,  but  at 
the  same  time  is  so  contracted  as  to  prevent  the  foot  being  placed 
beyond  a  right  angle  with  the  leg.  This  condition  is  spoken  of  as 
right-angled  contraction  of  the  tendo  Achillis  or  as  rectangular 
talipes. 

2.  Talipes  varus  is  the  most  complicated  variety  of  club-foot, 
and  is  the  most  common  of  the  congenital  forms.  By  some  the 
distortion  here  described  as  varus  is  called  equino-varus.  I  pre- 
fer, however,  to  apply  the  simple  term  varus  to  the  form  under 
consideration,  and  equino-varus  to  cases  of  equinus  in  which 
there  is  added  a  secondary  twisting  inwards  of  the  foot.  In  varus 
(Fig.  372),  the  OS  calcis  is  drawn  up  by  the  tendo  Achillis,  tilting 
the  astragalus  partially  out  of  the  ankle-joint,  and  the  bones  in 
front  of  the  transverse  tarsal  joint  are  drawn  inwards  and  upwards 
by  the  tibialis  anticus  and  posticus,  so  that  the  scaphoid  is  placed 
internal  to  the  astragalus  instead  of  in  front  of  it,  whilst  its  tube- 
rosity is  in  close  contact  with  the  internal  malleolus.  The  liga- 
ments on  the  inner  side  of  the  sole  and  between  the  tibia  and 
astragalus  are  shortened,  and  are  often 
the  chief  agents  holding  the  bones  in  their 
deformed  position.  In  severe  cases,  how- 
ever, the  astragalus  is  itself  deformed,  its 
head  looking  almost  directly  inwards,  in- 
stead of  forwards  and  slightly  inwards. 
Thus,  in  a  well  marked  case  (Fig.  373  a 
and  b),  the  heel  appears  drawn  up,  the 
anterior  part  of  the  foot  ad  ducted  and 
inverted,  the  inner  border  turned  upwards 
or  inverted,  and  the  outer  border  down- 
wards, so  that  the  sole  looks  backwards 
and  the  dorsum  forwards,  the  long  axis  of 
the  foot  being  at  the  same  time  shortened 
and  bent  upon  itself,  the  sole  unnaturally 
concave,  and  the  plantar  fascia  tense.  In  severe  cases  (Fig.  373c) , 
the  inner  border  of  the  foot  may  be  in  contact  with  the  leg, 
and  when  the  foot  has  been  walked  upon  the  sole  looks  upwards. 


Fig.  372. 


Congenital  talipes  varus.  'St. 
Bartholomew's  Hospital  Mu- 
seum.) 


778 


DISEASES   OF   REGIONS. 


as  well  as  backwards,  and  the  dorsum  downwards  as  well  as 
forwards ;  whilst  the  sole  is  narrowed  by  the  approximation  of 
the  fifth  metatarsal  bone  to  the  first,  and  a  bursa  often  forms 
over  the  outer  border  of  the  dorsum.  In  the  acquired  form, 
which  is  generally  due  to  infantile  paralysis,  the  history  of  the 
case,  the  wasting,  shortening,  coldness  and  passive  congestion  of 
the  hmb,  and  often  the  absence  of  rig^'dity,  will  commonly  serve 
to  distinguish  it  from  the  congenital. 

3.  Talipes  calcaneus  is  rare.  In  the  congenital  variety  (Fig. 
374)  the  anterior  part  of  the  foot  is  drawn  up  and  often  a  little 
everted  or  inverted,  and  generally  held  rigidly  in  this  position  by 
the  contraction  of  the  extensor  muscle?.  In  the  acquired  form 
(Fig.  374),  which  is  commonly  the  result  of  infantile  paralysis  of 

Fig.  373. 


Congenital  varus.     Three  grades  of  severity.     (Bryant's  Surgery.) 

the  calf  muscles,  the  heel  is  placed  first  on  the  ground  in  walking, 
but  there  is  no  drawing  up  of  the  foot  by  the  extensors.  The 
anterior  part  of  the  foot  drops  downwards  from  the  transverse 

Fig.  374. 


Acf./i/ir(i^ 


(.'ox(/r/iilei7. 


Talipes  calcaneus.      (Bryant's  .Surgery.) 


tarsal  joint,  and  the  tendo  y\rhi]lis,  instead  of  standing  out  tensely 
as  in  the  normal  foot,  can  often  hardly  l)e  felt. 

4.  In  talipes  valgus  or  flat-foot  the  longitudinal  and  transverse 
arches  of  the  foot  are  flattened  and  the  anterior  part  of  the  foot 


TALIPES    OR    CLUB-FOOT.  779 

is  more  or  less  everted.  Though  rare  as  a  congenital,  it  is  very 
common  as  an  acquired  deformity,  and  as  such  is,  perhaps,  most 
often  due  to  the  yielding  of  the  ligaments  of  the  sole  and  the  re- 
laxed state  of  the  muscles  which  normally  support  the  plantar 
arches,  in  consequence  of  general  debility  and  want  of  muscular 
tone,  combined  with  long-standing  or  carrying  heavy  weights 
with  the  feet  abducted.  Hence  its  frequency  in  growing  and 
under-fed  lads,  errand-boys,  policemen,  waiters,  housemaids,  and 
the  like.  Amongst  other  causes  may  be  mentioned  rheumatism, 
gonorrhoea,  rickets,  sprains  of  the  plantar  ligaments,  and  spasm 
or  paralysis  of  certain  muscles  of  the  leg.  It  is  also  met  with  in 
badly-set  cases  of  Pott's  fracture.  The  calcaneo-scaphoid  liga- 
ment and  plantar  fascia,  and  to  a  less  extent  the  other  ligaments 
of  the  sole,  are  elongated,  and  the  bones  on  the  inner  side  of  the 
foot,  instead  of  forming  an  arch,  are  depressed  and  in  contact 
with  the  ground.  The  bones  in  front  of  the  transverse  tarsal 
joint  are  at  the  same  time  more  or  less  abducted  and  everted, 
leaving  the  head  of  the  astragalus,  which  is  itself  depressed,  partly 
exposed  on  the  inner  side  of  the  foot. 

In  severe,  and  generally  in  congenital  cases,  the  heel  and  front 
of  the  foot  are  drawn  up  by  the  tendo  Achillis  and  the  anterior 
muscles  respectively,  whilst  the  outer  border  of  the  foot  is  raised 
from  the  ground.  The  acquired  form  is  often  productive  of  so 
much  crippling  and  pain  as  to  render  the  sufferer  unable  to  follow 
any  employment  which  necessitates  much  standing  or  walking. 
The  foot  (Fig.  375)  looks  broader  and  longer  than  natural,  the 
sole  is  flat,  the  inner  border  in  contact  with  the  ground,  and  the 
internal  malleolus  depressed  ;  whilst  two  prominences,  formed  by 
the  tuberosity  of  the  scaphoid  and  the  partially  exposed  head  of 
the  astragalus,  can  be  seen  and 
felt  projecting  on  the  inner  side  Fig.  375. 

of  the  foot.     In  slight  cases  the 

foot  can  be  made  to  assume  its  "| 

natural  form  on  manipulation  or  |, 

on  standing  on  tip-toe,  but  in  / 

severe  cases  it  is  rigidly  fixed  in 
the  deformed  position.  Pain 
and  stiffness  of  the  metatarso- 
phalangeal joint  of  the  great  toe 
{HaJ/i/x  dolorosus)  is  a  com- 
mon concomitant  of  flat-foot  in 

boys  and  young  adults.  Talipes   valgus   or  flat-foot.     (St.  Bartholo- 

5.    In  talipes  CaVllS  the  sole   is  ™<=^^'s  Hospital    xMuseumt. 

unnaturally  arched  and  the  plan- 
tar fascia  is  tense.     The  toes  are  often  extended  at  the  metalarso- 


78p  DISEASES   OF   REGIONS. 

phalangeal  joint,  and  flexed  at  the  first  interphalangeal  joints, 
giving  them  a  clawed  appearance  (hollotu  clazv-foot).  This  con- 
dition is  said  at  times  to  be  due  to  infantile  paralysis  affecting  the 
interosseous  muscles.  I  have  tested  the  muscles  in  many  cases, 
but  have  not  found  them  paralyzed. 

General  treatment  of  Talipes. — The  indications  are — i,  to 
restore  the  deformed  foot  to  its  natural  position;  and  2,  to  retain 
it  in  this  position  until  the  normal  functions  of  the  joints  and 
muscles  have  been  so  far  restored  that  there  is  no  tendency  to  a 
relapse.  In  the  congenital  and  in  many  of  the  acquired  forms 
these  indications  can  be  successfully  fulfilled  if  appropriate  means 
are  taken  and  sufficient  time  and  care  are  given  to  the  case.  But  in 
the  paralytic  varieties,  where  the  muscles  have  undergone  com- 
plete atrophy  and  degeneration,  these,  of  course,  cannot  be  re- 
stored, and  the  foot  can  only  be  maintained  in  the  normal  posi- 
tion by  the  use  of  instruments.  For  the  fulfilling  of  the  first  indi- 
cation both  operative  and  mechanical  or  manipulative  treatment 
may  be  necessary.  For  the  second,  the  use  of  mechanical  sup- 
ports and  physiological  after-treatment  should  be  employed. 

The  operative  trea/menf,  when  this  is  necessary,  will  generally 
consist  in  the  subcutaneous  division  of  certain  tendons  {tenotomy^, 
in  the  division  of  contracted  ligaments  {syndesmotomy),  and  in  in- 
veterate cases  in  the  excision  or  section  of  some  of  the  tarsal  bones 
{tarsectomx  or  /arso/o/iiy),  or  in  the  performance  of  one  or  other  of 
the  following  operations  : — Phelps'  open  incision  ;  Buchanan's  sub- 
cutaneous section  ;  Fitzgerald's  operation  ;  forcible  rectification. 

Tenotomy  is  indicated  where  there  is  much  rigidity  and  the 
foot  cannot  be  brought  into  its  natural  position  by  manipulation. 
Its  object  is  the  lengthening  of  the  shortened  tendon,  not  its 
mere  division.  The  lengthening  is  effected  by  the  organization  of 
the  small-cell-exudation  which  is  poured  out  between  the  divided 
ends  of  the  tendon.  Hence  the  importance  of  subcutaneous 
division,  that  is,  of  making  a  mere  puncture  in  the  skin  and  pre- 
venting the  entrance  of  septic  matter,  lest  suppuration  ensue  and 
the  tendon  become  adherent  to  its  sheath  or  fail  to  unite.  The 
tendon  having  been  made  tense  by  an  assistant,  pass  the  teno- 
tome beneath  it  with  the  blade  on  the  flat ;  then  whilst  the  ten- 
don is  slightly  relaxed,  turn  the  edge  of  the  tenotome  towards  the 
tendon  and  cut  towards  the  skin,  the  assistant  again  making  it 
tense  to  facilitate  the  division,  but  relaxing  the  moment  it  is  felt 
to  give  way,  lest  the  skin  be  severed  and  the  puncture  be  con- 
verted into  an  open  wound.  The  puncture  should  be  covered 
with  a  dossil  of  antiseptic  gauze,  and  the  foot  secured  to  a  splint 
or  in  a  plaster-of- Paris  bandage.  It  was  formerly  the  custom  to 
place  the  foot  in  a  spHnt  in  the  deformed,  or  in  only  a  slightly 


TALIPES   OR    CLUE-FOOT.  781 

improved  position  for  a  few  days  until  the  puncture  had  healed 
and  the  tendon  had  united,  before  beginning  mechanical  exten- 
sion to  stretch  the  new  material  between  the  divided  ends.  It 
was  thought  that  if  the  foot  was  at  once  rectified  and  the  ends  of 
the  divided  tendon  consequently  much  separated,  there  was  grave 
risk  of  the  tendon  not  uniting,  or  of  the  uniting  material  remain- 
ing weak.  I  have  not,  however,  found  this  to  be  the  case ;  and  I 
now  invariably  place  the  foot  immediately  after  tenotomy  in  the 
best  position  possible,  often  leaving  a  gap  a  quarter  of  an  inch  to 
half  an  inch,  or  even  more,  between  the  ends  of  the  divided  ten- 
don. By  at  once  rectifying  the  position  of  the  foot,  after  divid- 
ing any  contracted  ligaments  that  may  still  hold  the  bones  in 
their  deformed  position,  much  time  is  saved  and  the  necessity  of 
expensive  extension-apparatus  is  avoided.  In  dividing  the  pos- 
terior tibial  tendon,  after  a  puncture  has  been  made  with  a  sharp- 
pointed  tenotome,  a  blunt-pointed  tenotome  should  be  substituted 
for  it  lest  the  posterior  tibial  artery  be  pricked.  Should  this  ves- 
sel be  wounded,  all  that  is  necessary  is  to  apply  firm  pressure  to 
the  foot  and  ankle  by  a  pad  and  l)andage.  On  no  account  should 
an  attempt  be  made  to  tie  it,  as  this  would  convert  the  subcuta- 
neous into  an  open  wound.  Even  where  the  anterior  as  well  as  the 
posterior  tibial  artery  has  been  wounded  in  tenotomy,  bleeding 
has  been  readily  arrested  by  pressure,  and  no  harm  has  ensued. 
In  the  fat  ankle  of  an  infant  the  posterior  border  of  the  tibia,  the 
guide  to  the  tendon  of  the  tibialis  posticus,  cannot  be  felt ;  the 
tenotome  should  then  be  entered  midway  between  the  anterior 
and  posterior  border  of  the  leg,  and  at  right  angles  to  the  surface. 

Syndesuwtomy  consists  in  dividing  the  contracted  ligaments 
which,  after  tenotomy,  are  frequently  found  to  hold  the  foot  in  the 
deformed  position.  It  is  performed  by  passing  a  tenotome  deeply 
into  the  foot  over  the  situation  of  the  ligaments  to  be  divided,  and 
cutting  freely  through  them  whilst  they  are  put  on  the  stretch  by 
an  assistant  manipulating  the  foot.  The  position  of  the  foot  should 
then  be  rectified  by  wrenching,  and  a  plaster-of-Paris  bandage 
applied. 

Tarsectomy  has  for  its  object  the  removal  of  certain  bones  or 
portions  of  bones  from  the  tarsus,  so  as  to  allow  the  foot  to  be  at 
once  restored  to  its  normal  position.  It  should  only  be  under- 
taken in  inveterate  cases  after  milder  measures  have  failed.  The 
operations  most  frequently  performed  are  Davy's,  or  the  removal 
of  a  wedge-shaped  piece  of  bone  from  the  tarsus,  and  Lund's,  or 
the  excision  of  the  astragalus. 

Tarsotomy  is  the  operation  of  dividing  the  tarsus  transversely 
with  a  chain  saw,  and,  like  tarsectomy,  should  only  be  done  in 
inveterate  cases. 


782  DISEASES   OF   REGIONS. 

Phelps^  open  incision  consists  in  making  an  incision  through 
the  soft  tissues  on  the  inner  side  of  the  loot  down  to  the  bones. 
The  tibialis  anticus  and  posticus,  the  abductor  haUucis  and  the  cal- 
caneo-scaphoid  ligaments  are  divided.  The  wound  is  then  stuffed 
with  aseptic  gauze  and  allowed  to  granulate  from  the  bottom. 

Buchanan's  subcuiatieoits  section. — A  tenotomy  knife  is  passed 
between  the  skin  and  the  plantar  fascia  half  across  the  sole  of  the 
foot,  and  all  soft  parts,  the  muscles,  arteries,  nerves,  and  ligaments, 
are  then  divided  down  to  the  calcaneo-scaphoid  joint. 

Fitzgerald' s  operation  consists  in  dividing  subcutaneously  with  a 
chisel  the  neck  of  the  astragalus  and  the  os  calcis  just  behind  the 
posterior  articular  ficet  for  the  astragalus,  and  in  then  drilling  the 
cuboid  in  several  places,  breaking  up  subcutaneously  the  scaphoid 
with  a  chisel  and  hammering  it  back  into  place. 

Forcible  rectification. — This  is  done  by  a  Thomas  wrench  or  by 
Grattan's,  Redard's,  or  some  other  form  of  osteoclast.  The  liga- 
ments preventing  reduction  are  torn  across,  and  sometimes  the 
bones  are  broken. 

Mechanical  treatment. — Until  recently  it  was  usual  to  keep  the 
foot  in  the  deformed  position  till  the  tendons 
Fi'^s?^-  had  united,   and   then   bring  the   foot  slowly 

into  its  normal  position  by  gradually  stretching 
the  divided  tendon.  The  apparatus  usually 
em.ployed  was  some  form  of  Scarpa's  shoe  (Fig. 
376)  or  other  cog-wheel  contrivance.  By  the 
majority  of  Surgeons,  however,  plaster-of-Paris 
is  now  substituted  for  such  expensive  apparatus, 
the  foot  being  secured  at  once  in  the  plaster  in 
the  best  possible  position.  In  slight  cases  divi- 
sion of  the  tendon  will  alone  be  sufficient  to 
allow  of  this  ;  in  more  severe  cases  the  division 
Scarpa's  shoe.  of  the  ligamciits  will  also  be  necessary,  whilst 

in  very  severe  cases  removal  of  a  portion  of 
bone  will  be  required.  If  plaster-of-Paris  is  used,  a  cotton-wood 
bandage  should  always  be  employed  beneath  the  plaster  to  pre- 
vent injurious  pressure  on  the  parts.  The  mechanical  supports 
necessary  after  the  foot  has  been  rectified  will  be  briefly  men- 
tioned under  the  treatment  of  each  variety  of  talipes. 

Physiological  after-treatment  is  most  important  for  the  purpose 
of  restoring  the  natural  movements  of  the  joints  and  the  func- 
tional activity  of  the  muscles.  It  consists  in  active  and  passive 
exercises,  massage,  Faradization,  hot  and  cold  sponging,  and 
lastly  in  teaching  the  patient  the  proj^er  use  of  the  restored  foot. 
It  now  remains  to  mention  the  special  treatment  appropriate 
to  each  variety  of  talipes. 

In  talipes  equinus,  tenotomy  of  the  tendo  Achillis  is  usually  all 


TALIPES   OR    CLUB-FOOT. 


783 


Fig.  377. 


Boot  with  double  leg- 
irons  to  above  knee, 
outside  iron  contin- 
ued 10  pelvic  girdle. 


that  is  required  ;  but  if  there  is  much  contraction  of  the  sole 
{talipes  cavus),  the  plantar  fascia,  or  any  tense  band  that  can  be 
felt,  should  first  be  divided,  and  when  the  sole  has  been  straight- 
ened out  by  keeping  the  foot  for  a  fortnight  or 
so  in  plaster  of  Paris,  the  tendo  Achillis  may  then 
be  cut,  and  the  foot  again  placed  in  plaster  in 
the  restored  position  for  another  two  or  three 
weeks.  A  boot  with  double  leg-irons  and  toe- 
raising  spring  must  be  subsequently  worn  in  par- 
alytic cases,  the  irons  being  carried  above  the 
knee  and  the  outer  band  above  the  hip  to  a 
pelvic  band  if  the  flexors  or  extensors  of  the  leg 
are  also  affected  (Fig.  377). 

In  talipes  vanes,  except  in  slight  cases,  the 
tibialis  anticus  and  posticus  should  first  be  di- 
vided, and  the  inversion  of  the  foot  overcome 
by  some  form  of  varus  sphnt,  or  plaster  of  Paris. 
VVhen  this  has  been  thoroughly  done,  the  tendo 
Achillis  should  be  cut,  and  the  heel  brought  down 
as  in  equinus.  Where  there  is  much  contraction 
of  the  sole,  the  plantar  fascia,  or  other  tense 
band,  should  be  divided  after  the  tibials,  but 
before  the  tendo  Achillis.  A  similar  instrument 
to  that  described  for  equinus  should  then  be  worn  for  six  months 
to  a  year  or  more,  or  as  long  as  any  tendency  is  shown  to  relapse. 
In  paralytic  cases,  where  the  whole  leg  tends  to  twist  inwards 
from  the  hip-joint,  the  outer  iron  should  be  carried  to  the  pelvis. 
In  very  severe  cases  the  ligaments  on  the  inner  side  of  the  sole 
and  the  posterior  ligament  of  the  ankle  may  be  divided  subcu- 
taneously,  as  suggested  by  Mr.  R.  W.  Parker  {syndesmotomy);  or, 
if  this  is  not  enough,  the  whole  of  the  soft  tissues  on  the  inner 
side  of  the  sole  may  be  divided  subcutaneously  down  to  the  bone 
{Bitchanan'' s  operation),  or  the  contracted  tendons  and  ligaments 
below  and  in  front  of  the  internal  malleolus  may  be  divided  by 
an  open  incision  (^Phelps'  operation),  or  as  a  last  resource  a 
wedge-shaped  piece  from  the  transverse  tarsal  joint,  or  the  astra- 
galus, may  be  removed. 

In  talipes  calcaneus,  the  extensor  tendons,  in  the  congenital 
form,  must  be  divided  if  the  foot  cannot  be  rectified  by  plaster 
of  Paris  alone.  In  the  acquired  form  a  boot  and  irons,  similar 
to  that  used  in  equinus  but  with  a  toe- depressing  spring,  may  be 
worn.  In  paralytic  cases  the  tendo  Achillis  may  in  some  in- 
stances be  shortened  by  removing  half  an  inch  or  more  and  splic- 
ing the  divided  ends,  or  the  peronei  may  be  sutured  to  the  tendo 
Achillis  so  as  to  take  the  place  of  the  paralyzed  calf  muscles 
{NicolodonPs  operation) . 


784  DISEASES   OF   REGIONS. 

In  talipes  valgus  or  flat-foot,  such,  exercises  as  alternately  raising 
the  body  on  tip-toe,  or  walking  on  the   outer 
Fig.  378.  edge  of  the   foot,  will  in  slight  cases  of  the  ac- 

quired variety  when  combined  with  the  use  of  a 
valgus  pad  and  a  properly  shaped  boot,  gener- 
ally be  successful.  In  severer  cases  a  boot  with 
outside  leg-iron  and  rubber  band  to  brace  up 
the  sunken  arch  (Fig.  378),  should  be  worn; 
whilst  where  there  is  much  rigidity,  the  foot 
should  be  wrenched  into  position  with  the  pa- 
tient under  an  anaesthetic  and  placed  in  plaster 
of  Paris  for  a  month.  The  wrenching  may  be 
repeated  if  necessary,  and  the  boot  above  de- 
,    ,    ,  ^     ,    „        scribed    subsequentlv   worn.      In    very   severe 

Author  s  boot  for  flat-  ..  r  r^i    '  ■,      ■     •         /^i 

foot.  cases  excision  01  Lhopart  s  jomt  {Ogston  s  oper- 

ation), the  removal  of  a  wedge-shaped  piece  of 
the  neck  of  the  astragalus,  and  osteotomy  of  the  tibia  just  above 
the  ankle,  have  been  performed,  and  are  said  to  be  attended  with 
success.  I  have  on  only  one  occasion  had  to  do  Ogston's  oper- 
ation, having  always  found  wrenching  sufficient.  By  some  Sur- 
geons division  of  the  peronei  tendons  is  recommended,  a  pro- 
cedure which  in  my  opinion  is  quite  unnecessary,  and  contrary  to 
the  principles  which  should  guide  us  in  the  treatment  of  the 
deformity. 

Hallux  valgus  is  the  dislocation  of  the  great  toe  inwards  at 
the  metatarso-phalangeal  joint.  It  is  frequently  connected  with 
an  enlarged  bunion  over  the  inner  side  of  the  joint.  In  the  way 
of  treatment  a  sock  with  a  separate  stall  for  the  big  toe  should  be 
worn,  and  the  boots  should  be  straight  along  the  inner  edge  and 
square  at  the  toe.  Krohne's  lever.  Bigg's  bunion  spring,  or 
Holden's  toe-post  in  the  boot,  will  be  found  useful  in  correcting 
the  inward  displacement.  If  the  toe-post  is  used  a  gloved  stock- 
ing must  be  worn.  For  advanced  cases,  excision  of  the  head  of 
the  metatarsal  bone  is  attended  with  the  best  results. 

Hammer  toe  is  a  condition  in  which  usually  the  second  toe  is 
hyperextended  at  the  metatarso-phalangeal  joint  and  flexed  at  the 
first  interphalangeal  joint.  It  is  due  to  contraction  of  the  lateral 
ligaments  and  glenoid  plate  (not  to  contraction  of  the  tendons), 
the  result  in  probably  the  majority  of  cases  of  wearing  too  short 
or  badly-shaped  boots.  It  is  sometimes  hereditary,  however,  and 
Mr.  Anderson  regards  it  as  due  to  a  physiological  contraction  of 
the  ligaments,  and  only  in  a  remote  sense  to  the  use  of  ill-formed 
boots.  Treatment. — Wrenching  the  toe,  dividing  the  ligaments 
subcutaneously,  excising  the  joint,  or  am]nitating  the  toe,  accord- 
ing to  the  degree  of  the  deformity,  is  the  proper  treatment. 


APPENDIX. 


AMPUTATIONS. 

Amputations. — The  objects  that  should  be  kept  in  view  in 
performing  an  amputation  are  :  i.  To  remove  the  whole  of  the 
injured  or  diseased  part  that  is  beyond  the  reach  of  recovery, 
with  as  little  sacrifice  of  the  healthy  tissues  as  possible.  2.  To 
prevent  all  unnecessary  haemorrhage.  3.  To  secure  a  sufficient 
covering  for  the  end  of  the  bone.  4.  To  avoid  adhesion  of  the 
cicatrix  to  the  bone.  5.  To  divide  the  large  blood-vessels  and 
nerves  transversely,  and  leave  their  cut  ends  in  such  a  part  of  the 
stump  that  they  may  be  Httle  exposed  to  pressure.  6.  To  ensure 
an  efficient  drain  and  aseptic  condition  of  the  wound. 

Amputations  may  be  performed  by  the  circular  or  by  t\\t  flap 
method. 

In  the  circular  method  the  integuments  are  first  divided  by  a 
circular  incision  round  the  entire  circumference  of  the  limb. 
They  are  then  retracted,  and  the  muscles  divided  higher  up  the 
limb  by  a  similar  circular  sweep  of  the  knife.  The  muscles  are 
next  in  their  turn  retracted,  and  the  periosteum  is  divided  still 
higher  up  the  bone,  which  is  finally  sawn  through  at  that  spot. 
This  method  possesses  the  advantages  that  the  vessels  and  nerves 
are  divided  transversely,  and  that  the  wound  is  of  moderate 
dimensions  ;  but  the  cicatrix  is  opposite  the  end  of  the  bone,  the 
coverings  for  the  latter  are  apt  to  be  deficient,  and  the  stump  is 
liable  to  assume  a  conical  shape.  The  circular  method  is  now 
seldom  employed,  except  for  amputation  of  the  arm. 

In  iht  flap  me/hod,  double  flaps,  or  a  single  anterior  or  posterior 
flap,  are  provided  for  the  covering  of  the  bone.  The  flap  or  flaps 
may  consist  of  integuments  alone,  or  of  more  or  less  of  the  mus- 
cular and  other  soft  tissues  as  well.  In  the  former  case  the  flaps 
are  cut  and  reflected,  and  the  muscles  and  other  soft  parts  are 
then  divided  at  the  level  of  the  base  of  the  flaps  in  a  circular 
manner  down  to  the  bone,  which  is  sawn  through  a  little  higher 
up.  By  this  method  most  of  the  advantages  of  the  circular  ampu- 
tation are  secured,  without  its  disadvantages.  When,  on  the  other 
hand,  the  muscles  are  included  in  the  flaps,  the  vessels  and  nerves 
are  Hable  to  be  split,  or  notched,  or  'divided  obliquely  instead  of 
transversely,  whilst  the  mass  of  muscle  in  the  flap  tends  to  prolong 
the  healing  of  the  wound.  These  muscular  flaps  may  be  cut  either 
2>Z*  (  785  ) 


786  APPENDIX. 

from  without  inwards,  /.  e.,  from  the  circumference  towards  the 
bone,  or  from  within  outwards,  /.  e.,  by  the  method  of  transfixion. 
In  whichever  way  the  flaps  are  cut,  and  whether  they  consist  of 
integimients  only,  or  of  integuments  and  muscle,  they  may  as  re- 
gards position  be  antero-posterior  or  lateral,  or  one  may  be  antero- 
external  and  the  other  postero-internal,  or  vice  versa.  As  regards 
length  they  may  be  equal,  or  one  may  be  long,  the  other  short ;  and 
as  regards  breadth  they  should  be  half  the  circumference  of  the 
limb.  As  a  rule  they  should  be  cut  square,  but  with  rounded  angles. 
The  following  modifications  of  the  flap  operation  may  be  briefly 
mentioned. 

Teak's  method  consists  in  making  a  long  and  short  rectangular 
flap  (Fig.  379).     The   long  flap,  which   is  generally  anterior,  or 

Fig.  379. 


Tealc's  amputation.     (Bryant's  Surgery.) 

antero-external,  is  quadrilateral  in  shape,  and  its  length  and 
breadth  each  equal  to  half  the  circumference  of  the  limb;  it 
includes  all  the  soft  parts  down  to  the  bone.  The  short  flap  is 
posterior,  or  postero-internal ;  its  length  is  one-fourth  the  anterior, 
and  its  breadth  equal  to  half  the  circumference  of  the  limb  ;  it 
also  includes  all  the  soft  parts  down  to  the  bone,  and  contains  the 
large  vessels  and  nerves.  When  the  operation  is  completed  and 
the  wound  closed,  the  stump  presents  the  appearance  shown  in 
the  lower  half  of  Fig.  379.  The  advantages  claimed  for  Teale's 
method  are  :  i.  Freedom  from  tension.  2.  A  complete  covering 
for  the  bone,  free  of  large  vessels  and  nerves  ;  and  3.  A  dependent 
position  of  the  wound.  It  is  applirable  to  amputations  through 
the  leg,  arm,  forearm  and  lower  third  of  the  thigh. 

Garden's  7nelhod,  designed   for  amputating  through   the  con- 


SPECIAL   AMPUTATIONS.  787 

dyles  of  the  femur,  consists  in  reflecting  a  semi-oval  flap  of  integ- 
uments, half  the  circumference  of  the  limb  in  length  and  breadth, 
from  the  front  of  the  knee-joint,  dividing  everything  else  down  to 
the  bone  by  a  circular  sweep  of  the  knife  and  sawing  the  bones 
across  slightly  above  the  plane  of  the  divided  muscles. 

Special  amputations. — Amputation  at  the  shoulder-joint  may  be 
performed  either  by  the  flap  or  by  the  oval  method.  In  either 
case  the  subclavian  artery  should  be  compressed  above  the  clav- 
icle, or  in  some  instances  the  axillary  tied  before  the  amputation 
is  begun.  The  flap  method. — A  large  flap  consisting  of  integu- 
ments and  deltoid  muscle  is  usually  taken  from  the  outer  aspect 
of  the  joint,  either  by  transfixion  or  better  by  cutting  from  with- 
out inwards.  In  transfixion,  the  deltoid  having  been  grasped 
and  raised  by  the  Surgeon's  left  hand,  the  knife  should  be  made 
to  transfix  the  limb  on  its  upper  and  outer  aspect  just  below  the 
acromion,  and  a  flap  formed  with  rounded  angles  about  four 
inches  long.  The  flap  is  turned  back,  the  head  of  the  bone  freed 
from  its  connections,  and  the  knife  passed  behind  it,  and  made  to 
cut  its  way  out  towards  the  axilla,  the  axillary  artery  being  seized 
as  it  is  divided.  In  cutting  a  flap  from  without  inwards,  the  in- 
cision is  made  from  a  point  just  external  to  the  coracoid  process 
and  carried  in  a  circular  sweep  downwards  as  low  as  the  insertion 
I  of  the  deltoid,  and  then  upwards  to  the  posterior  fold  of  the 
'  axilla  just  behind  and  below  the  acromion.  In  the  oval  method 
{Spence's  niodification),  an  incision  is  made  from  just  external  to 
the  coracoid  vertically  downwards  as  in  excising  the  joint, 
"through  the  clavicular  fibres  of  the  deltoid  and  pectoralis 
major"  to  the  humeral  attachment  of  the  latter  muscle,  which  is 
then  divided.  The  incision  is  next  carried  with  a  gentle  curve 
through  the  lower  fibres  of  the  deltoid  towards  the  posterior 
border  of  the  axilla.  A  second  incision  is  then  made  through  the 
skin  and  fat  only,  from  the  point  where  the  straight  incision  ter- 
minated across  the  inside  of  the  arm,  to  meet  the  incision  at  the 
outer  part.  The  outer  flap  is  next  dissected  up  with  the  trunk  of 
the  posterior  circumflex  artery,  the  head  freed  from  its  connections, 
disarticulated,  and  the  remaining  soft  parts  cut  through  on  the 
axillary  aspect,  the  axillary  artery  being  divided  last  of  all. 

Amputations  of  the  arm  and  forearm  are  usually  performed  by 
double  skin-flaps  and  circular  division  of  the  muscles.  The  cir- 
cular method,  however,  or  amputation  by  single  or  double  trans- 
fixion or  by  Teale's  method,  may  be  employed. 

Amputation  at  the  wrist  may  be  performed  by  two  short  flaps,  by 
a  long  palmar  flap,  or  by  an  external  flap  taken  from  the  thumb. 
In  the  double-flap  method  the  incision  is  commenced  half  an  inch 
above  the  styloid  process  of  the  radius  or  ulna.     The  flaps  should 


788  APPENDIX. 

be  cut  square,  with  rounded  angles,  and  about  two  inches  in 
length.  The  joint  should  be  opened  on  the  dorsal  aspect,  and  on 
the  completion  of  the  disarticulation  the  styloid  processes  of  the 
radius  and  ulna  sawn  off. 

The  thumb  at  the  carpo-metacarpal  joint  may  be  amputated  by 
transfixion  or  by  an  oval  incision.  In  the  transfixion  method  the 
point  of  the  knife  in  operating  on  the  right  side  is  entered  at  the 
web  of  skin  between  the  first  and  second  metacarpal  bones,  and 
made  to  emerge  on  the  palmar  aspect  of  the  carpo-metacarpal 
joint.  A  palmar  flap  is  then  cut  from  the  tissues  forming  the  ball 
of  the  thumb,  and  the  knife  drawn  obliquely  across  the  back  of 
the  thumb  from  one  extremity  of  the  flap  to  the  other.  In  ope- 
rating on  the  left  side,  the  oblique  incision  across  the  back  of  the 
thumb  is  first  made,  then  the  point  of  the  knife  is  thrust  down 
through  the  web  and  made  to  transfix  as  on  the  right  side.  In 
the  oval  <?r  circular  method,  the  knife  is  entered  midway  between 
the  base  of  the  metacarpal  bone  and  the  styloid  process  of  the 
radius,  and  the  incision  carried  obliquely  along  the  dorsum  of  the 
metacarpal  bone  to  the  first  phalanx,  and  then  round  the  palmar 
surface  and  back  again  to  the  former  incision. 

The  fingers  may  be  amputated  by  double  flaps  or  by  a  long 
anterior  flap.  In  amyjutating  a  finger  it  should  be  remembered 
that  the  joint  is  in  front  of  the  knuckle.  If  the  whole  finger  re-, 
quires  removal,  the  head  of  the  metacarpal  bone  should  be 
nipped  off  with  bone  forceps,  unless  breadth  and  strength  of  hand 
is  the  chief  desideratum,  when  it  should  be  left. 

Amputation  at  the  hip-joint  may  be  done  by  trans^xion  or  by 
Furneaux  Jordan's  method.  Although  the  former  can  be  per- 
formed with  greater  celerity,  the  latter  is  by  far  the  better  opera- 
tion, as  it  is  attended  with  less  hgemorrhage  and  provides  a  much 
more  useful  stump.  In  the  transfixion  method  a  long  anterior 
flap  is  made  by  transfixion  and  cutting  towards  the  surface.  The 
knife  is  entered  midway  -between  the  anterior  superior  iliac  spine 
and  the  great  trochanter,  and  is  made  to  emerge  as  near  to  the 
tuberosity  of  the  ischium  as  possible.  A  flap  about  ten  inches 
long  is  then  cut,  the  vessels  being  seized  by  the  fingers  of  an  as- 
sistant, who  grasps  them  with  the  flap,  and  turns  it  upwards. 
The  limb  is  then  everted  and  extended  by  an  assistant,  the  joint 
opened,  the  head  of  the  bone  and  great  trochanter  freed  from 
their  connections  and  the  knife  carried  straight  out  posteriorly. 
Haemorrhage  should  be  controlled  by  Davy's  lever  in  the  rectum 
or  by  Lister's  abdominal  tourniquet.  In  Furneaux  'Jordan's 
method,  I-^smarch's  cord  tourni(|uet  having  been  applied,  a  circu- 
lar amputation  is  first  done  through  the  upper  third  of  the  thigh, 
and  all  the  vessels  secured.     The  tourniquet  is  then  removed  and 


SPECIAL   AMPUTATIONS.  789 

an  incision  carried  up  the  outer  side  of  the  thigh  to  the  great 
trochanter,  the  soft  parts  with  the  periosteum  separated  from  the 
bone,  the  joint  opened,  and  the  disarticulation  completed  by  free- 
ing the  remaining  connections  with  the  knife  kept  close  to  the 
bone. 

Amputation  through  the  knee  is  perhaps  best  done  by  lateral  flaps 
after  Stephen  Smith's  method.  Two  lateral  skin-flaps  are  cut  from 
each  side  of  the  limb,  the  incisions  beginning  in  front,  an  inch 
below  the  tubercle  of  the  tibia,  and  ending  behind  at  the  centre  of 
the  popliteal  space.  The  soft  tissues  are  next  divided  by  a  circular 
sweep  of  the  knife  just  below  the  patella,  and  the  tibia  then  sep- 
arated from  the  femur.  The  patella  is  left  in  the  stump.  The 
inner  flap  should  be  slightly  the  larger. 

Amputation  of  the  thigh  is  usually  done  by  double  skin-flaps  and 
circular  division  of  the  muscles.  The  flaps  may  be  antero- 
posterior, or  lateral ;  or  one  flap  may  be  antero-external  and  the 
other  postero-internal. 

Amputation  of  the  leg  may  also  be  done  by  two  skin-flaps  and 
circular  division  of  the  muscles,  or  by  Teale's  method.  The  pos- 
terior flap  is  sometimes  cut  by  transfixion.  The  sharp  edge  of 
the  tibia  should  be  cut  off  obliquely,  lest  it  subsequently  protrude 
through  the  skin.  The  division  of  the  fibula  should  be  completed 
before  that  of  the  tibia,  to  prevent  splintering.  Should  the  arteries 
retract,  as  they  are  apt  to  do  in  this  situation,  they  may  be  con- 
veniently drawn  down  by  a  tenaculum. 

Amputation  of  the  foot  may  be  done  by  one  of  the  following 
methods  : — 

Disarticuhition  at  the  ankle  joint  {Syme's  amputation)  consists 
in  removing  the  foot  at  the  ankle-joint,  cutting  off  the  ends  of  the 
tibia  and  fibula,  and  retaining  the  integuments  of  the  heel  as  a 
covering  for  the  bones.  An  incision  down  to  the  bone  is  made 
across  the  under  surface  of  the  heel  from  the  tip  of  the  external 
malleolus  to  a  little  behind  and  below  the  internal  malleolus,  /.  e., 
to  a  point  exactly  opposite  its  commencement.  This  incision 
should  incline  slightly  backwards,  so  as  to  cross  the  os  calcis  just 
in  front  of  the  tubercles  (Fig.  380,  i  to  o),  A  second  incision 
is  next  made  across  the  front  of  the  ankle  (Fig.  389,  o  to  i'),  the 
joint  opened,  the  lateral  ligaments  divided,  and  the  os  calcis 
cleared  from  its  posterior  and  lateral  connections  by  cutting  from 
above  downwards.  Syme,  however,  formed  his  heel- flap  by  dis- 
secting it  from  the  bone  from  below  upwards,  a  more  difficult  pro- 
cedure than  cutting  from  above  downwards,  as  is  now  always  done 
at  St.  Bartholomew's.  The  knife  should  be  kept  close  to  the 
bone  to  avoid  injuring  the  posterior  tibial  artery  or  button-holing 
the  integuments.     The  malleoli  and  a  thin  slice  of  the  tibia  are 


790 


APPENDIX. 


finally  sawn  off  (Fig.  380,  a).  The  anterior  tibial  and  plantar 
arteries  require  ligaturing  ;  the  latter  are  situated  at  the  extremity 
of  the  inner  side  of  the  heel-flap. 

Pirogoff's  operaiio7i  is  a  modification  of  Syme's.  It  differs  in 
that  the  posterior  part  of  the  os  calcis  is  left  in  the  heel-flap  to 
unite  with  the  sawn  end  of  the  tibia.  It  is  performed  in  a  similar 
manner,  save  that  the  sole  incision  is  carried  slightly  forward  in- 
stead of  backward  (Fig.  380,  o  to  4),  and  after  the  ankle-joint  is 
opened,  and  the  os  calcis  exposed,  the  posterior  part  of  the  latter 
is  sawn  off  (Fig.  380,  d)  instead  of  being  dissected  out.  The 
sawn  surface  of  the  os  calcis  is  then  turned  up  and  placed  in  con- 
tact with  the  sawn  end  of  the   tibia,  to  which  it  may  advan- 

FlG.  380. 


Diagram  of  the  articulations  of  the  foot  and  the  lines  of  incision  in  the  various  amputations. 

A,  line  of  incision  through  malleoli  in  Syme's  amputation,  i  to  O,  O  to  i',  line?  of  incision 
through  soft  parts  in  Syme's  amputation.  D,  line  of  incision  through  os  calcis  in  I'irogoU  's 
operation,  i  to  O,  ()  to  4,  lines  of  incision  through  soft  parts  in  I'irogoff 's  operation.  B, 
line  of  articulation  between  os  calcis  and  astralagus  behind,  and  cuboid  and  scaphoid  in  front. 
2  to  ,  to  2',  lines  of  incision  in  Chopart's  operation.  C,  line  of  articulation  between 
tarsus  and  metatarsus.     3  to  t,  t  to  3'.  lines  of  incision  in  tarso-metatarsal  operation. 


tageously  be  fixed  by  an  ivory  peg  driven  through  the  heel-flap 
and  OS  calcis  into  the  lower  end  of  the  tibia. 

The  Medio-tarsal  amputation  ( Chopart's)  consists  in  amputa- 
tion of  part  of  the  foot  through  the  transverse  tarsal  joint,  /.  e.,  the 
joint  formed  by  the  os  calcis  and  astralagus  behind,  and  the 
cuboid  and  scaphoid  in  front  (I'Mg.  380,  h)-  A  curved  incision 
with  its  convexity  forward  is  made  across  the  dorsum  of  the  foot 
from  immediately  behind  the  tubercle  of  the  scaphoid  to  a  point 
midway  between  the  tip  of  the  external  malleolus  and  the  base  of 
the  fifth  metatarsal  bone  (Fig.  380,  2  to  -|-).     The  extremities 


SPECIAL   AIMPUTATIONS.  791 

of  this  incision  are  connected  by  tracing  out  from  the  sole  a  flap 
which  should  reach  just  short  of  the  balls  of  the  toes,  and  should 
be  longer  on  its  inner  than  on  its  outer  side  (Fig.  380,  -^  to  2'). 
The  dorsal  hgaments  are  now  divided,  and  the  knife  is  passed 
beneath  the  bones  and  made  to  cut  its  way  outwards,  thus  com- 
pleting the  flap  already  marked  out  on  the  sole.  The  astragalus 
and  OS  calcis  are,  of  course,  left  in  the  stump.  The  chief  objec- 
tion that  has  been  urged  against  the  operation  is  the  tendency  of 
the  tendo  Achillis  to  draw  up  the  os  calcis,  and  consequently 
depress  the  anterior  part  of  the  stump  so  that  the  cicatrix  becomes 
the  lowest  part.  If  care,  however,  is  taken  to  make  the  dorsal 
incision  nearly  straight  across  the  foot,  this  drawing  up  of  the 
heel  can  to  a  great  extent  be  prevented  and  an  excellent  and 
useful  stump  may  be  obtained,  or  Tripier's  suggestion  may  be 
adopted,  and  the  under  surface  of  the  os  calcis  be  sawn  off  so  as 
to  leave  a  flat  surface  for  walking  upon. 

The  Tarso-metatarsal  atnpiitation  consists  in  removing  the  an- 
terior part  of  the  foot  at  the  joints  between  the  tarsus  and  meta- 
tarsus (Fig.  380,  c),  leaving  the  tarsus  intact.  It  may  be  done — 
I,  by  disarticulating  the  metatarsal  bones;  2,  by  sawing  across 
the  bases  of  all  the  metatarsal  bones  ;  3,  by  disarticulating  the 
four  outer  metatarsal  bones  and  sawing  across  the  projecting  in- 
ternal cuneiform  bone  ;  4,  by  disarticulating  the  three  outer  and 
the  first  metatarsal  bones,  and  sawing  across  the  prominent  base 
of  the  second.  The  disarticulating  method  is  usually  called  Lis- 
franc's  operation  ;  the  disarticulating,  with  sawing  across  the  in- 
ternal cuneiform  or  base  of  the  second  metatarsal  bone,  Hey's. 
Hey,  however,  it  appears,  performed  all  of  the  first  three  opera- 
tions, but  not  the  last ;  and  so  much  confusion  has  arisen  as  re- 
gards what  is  meant  by  Lisfranc's  and  what  by  Hey's  operation, 
that  the  terms  had  better  be  dropped.  In  the  disarticulating 
method,  which  only  need  be  described,  an  incision  is  made 
across  the  tarsus  from  the  fifth  metatarsal  bone  to  an  inch  in  front 
of  the  prominence  of  the  scaphoid  (Fig.  380,  3  to  t)  ;  a  sole-flap 
is  next  traced  out,  as  in  Chopart's  amputation,  but  it  should  reach 
as  far  as  the  web  of  the  toes  (Fig.  380,  f  to  3').  The  metatarsus 
is  then  disarticulated  from  the  tarsus,  the  only  difficulty  in  doing 
this  arising  from  the  second  metatarsal  bone  dipping  in  between 
the  cuneiform  bones.  The  knife  is  now  placed  behind  the  bones 
and  made  to  cut  its  way  out,  thus  completing  the  sole-flap,  or  the 
flap  if  preferred  may  be  dissected  up  from  without  inwards. 

^\\&  great  toe  may  be  amputated  at  its  tarso-metatarsal  joint  by 
a  flap  taken  from  the  inner  side  of  the  foot ;  or  by  an  oval  incis- 
ion which  is  carried  along  the  metatarsal  bone  to  about  the  mid- 
dle of  its  shaft,  then  made  to  diverge  to  the  web  between  the  first 


792  APPENDIX. 

and  second  toes,  and  carried  round  the  plantar  surface  of  the  big 
toe  and  back  to  the  spot  at  the  middle  of  the  metatarsal  bone. 
The  incision  should  extend  down  to  the  bone,  which  should  be 
next  freed  from  its  remaining  connections  and  disarticulated,  the 
knife  being  kept  close  to  the  metatarsal  bone  to  avoid  injuring 
the  communicating  branch  of  the  dorsalis  pedis  with  the  external 
plantar  artery.  When  the  operation  is  completed,  merely  a  single 
longitudinal  scar  remains  on  the  inner  side  of  the  foot. 


INDEX. 


ABDOMEN,  abscess  of,  377. 
contusions  of,  376. 

injuries  of,  376. 

protrusion  of  viscera  of,  392. 

rupture  of  muscles  of,  376. 
viscera  of,  377. 

tapping  of,  614. 

wounds  of,  379. 
Abdominal  parietes,  abscess  of,  377. 
wounds  of,  379. 

section,  605. 

viscera,  protrusion  of,  392. 
rupture  of,  377. 
wounds  of,  380,  392. 
Abscess,  35. 

acute,  35. 

aveolar,  533. 

anal,  660. 

of  bone,  223= 

of  brain,  344,462,  464,  477,  478. 

of  breast,  760. 

causes  of,  37. 

chronic,  40. 

complications  of  acute,  40. 

fcecal,  631. 

Hilton's  method  of  opening,  40. 

iliac,  587. 

ischio-rectal,  660. 

of  kidney,  668. 

lachrymal,  487. 

lumbar,  586. 

metastatic,  155. 

of  orbit,  504. 

perineal,  719. 

perinephritic,  668. 

postpharyngeal,  554,  586. 

of  prostate,  700. 

psoas,  586. 

residual,  41. 

spinal,  586. 

symptoms  of,  39, 

of  tongue,  519. 

treatment  of,  39,  41. 

urinary,  719. 


Abscesses,  embolic,  158. 

Acetabulum,  fracture  of,  395. 

Acinous  carcinoma,  93. 

Acne  rosacea,  540. 

Acromegaly,  230. 

Acromion,  fracture  of,  420. 

Actinomycosis,  152. 

Actinomyces,  153. 

Actual  cautery  in  haemorrhage,  130. 

Acupressure  in  haemorrhage,  133. 

Adenoid  cancer,  97. 

vegetations,  551. 
Adenoma,  91. 

acinous,  91. 

of  breast,  762. 

cystic,  91. 

tubular,  92. 
Adeno-fibroma,  91,  763. 

sarcoma,  91,  763. 
Air  in  veins,  204. 
Air-passages,  foreign  bodies  in,  360. 

operations  on,  566. 
Alveolar  abscess,  533. 
Amblyopia,  toxic,  500. 
Amputations,  785. 
Amussat's  operation,  612. 
Anal  abscess,  660. 

ulcer,  654. 
Anel's  operation,  282,  285. 
Aneurysm,  270. 

by  anastomosis,  310. 

arterio-venous,  202. 

of  bone,  236. 

causes  of,  270. 

circumscribed,  273. 

cirsoid,  310. 

classification  of,  272. 

contents  of,  272. 

diagnosis  of,  276. 

diffused,  273. 

dissecting,  273. 

effects  of,  275. 

false,  273. 

formation  of,  271. 


34 


(793) 


794 


INDEX. 


Aneurysm,  fusiform,  273. 

galvano-puncture  in,  287. 

irritation  of  interior  of  sac  by 
needles,  2S6. 

ligature  in,  2S1. 

manipulation  in,  2S6. 

pressure  in,  278. 

rupture  of,  274,  276. 

sacculated,  273. 

signs  of,  275. 

special,  287. 

spuvgmograph  in,  275. 

spontaneous,  270. 

structure  of,  271. 

suppuration  of,  284. 

terminations  of,  274. 

traumatic,  201. 

treatment  of,  277.  , 

true,  273. 

varicose,  202. 
Aneurysmal  varix,  202. 
Aneurjsms,  aortic,  288. 

at  bend  of  elbow,  290. 

axillar)',  289. 

carotid,  288. 

femoral,  291. 

gluteal,  290. 

inguinal,  290. 

internal,  287. 

in  neck,  287. 

orbital,  288. 

popliteal,  291. 
Angioma,  86,  309. 
Angular  curvature  of  spine,  584. 
Ankle,  amputation  at,  789. 

dislocation  of,  442. 

excision  of,  260. 

sprains  of,  429. 
Ankyloglossia,  518. 
Ankylosis,  bony,  254. 

fibrous,  254. 
Annular  stricture,  707. 
Anthrax  bacillus,  150. 
Antiseptic  treatment  of  wounds,  109. 
Antrum,  abscess  of,  534. 

catarrh  of,  553. 

cysts  of,  536. 

diseases  of,  534. 

tumors  of,  536. 
Antyllus,  operation  of,  for  aneurysm, 

281,  286. 
Anus,  artificial,  635,  641. 

diseases  of,  652. 

fistula  (^f,  660. 

imperforate,  652. 


Anus,  painful  ulcer  of,  654. 

prolapse  of,  655. 

pruritus  of,  653. 
Aphasia  after  head  injury,  343. 
Aphthous  stomatitis,  515. 
Appendicitis,  605. 
Arch,  palmar,  wounds  of,  403. 
Argyll-Robertson  pupil,  252,  509. 
Arm,  amputation  of,  787. 
Arterial  varix,  310. 
Arteries,  atheroma  of,  267, 

calcification  of,  269,  270. 

contusions  of,  196. 

diseases  of,  267. 

fatty  degeneration  of,  270. 

injuries  of,  196. 

laceration  of,  196. 

ligature  of,  131,  292. 

repair  of  wounds  of,  126,  199. 

rupture  of,  196. 

syphilitic  disease  of,  269. 

torsion  of,  132. 

treatment  of  wounds  of,  199. 

wounds  of,  198. 
Arterio-venous  aneurysm,  202. 
Arteritis,  267. 

plastic,  267. 

obliterative,  269. 

septic,  267. 

suppurative,  267. 

syphilitic,  269. 
Artery-forceps,  131. 
Arthrectomy,  256, 
Arthritis,  acute,  240. 

chronic  rheumatoid,  249. 
strumous,  243. 
tubercular,  243. 

deformans,  249. 

osteo-,  249. 
Artificial  anus,  635,  641. 

drum,  476. 
Ascites,  tap[)ing  abdomen  for,  614. 
Aspiration  in  abscess,  41. 

of  Ijladder,  727. 

of  kidney,  672. 

of  liver,  613. 
Asphyxia,  Laborde  method  of   treat- 
ing, 123. 
Astigmatism,  507. 
Astragalus,  dislocation  of,  443. 

fracture  of,  461. 
Atheroma,  267. 
Atheromatous  cyst,  99. 
Atlo-axoid  disease,  590. 
Atony  of  bladder,  681. 


INDEX. 


79t 


Atrophy  of  bone,  225. 
muscle,  261. 
optic  nerve,  500. 
testicle,  748. 
Auditory  vertigo,  481. 
Aural  exostosis,  473. 

forceps,  468,  472,  473. 
polypi,  476. 
specula,  468. 
Axillary  aneurysm,  289. 

artery,  ligature  of,  295. 

BACILLUS,  24. 
anthracis,  150. 

coli,  598. 

of  tetanus,  165. 

of  tubercle,  60. 
Back,  injuries  of,  362. 

sprams  of,  362. 
Bacteria,  parasitic,  25. 

pathogenic,  25. 

pyogenic,  38. 

saprophytic,  24. 
Bacterium  termo,  24. 
Baker's,  Morrant,  cysts,  238. 

operation  on  tongue,  525. 

tracheotomy  tube,  571. 
Balanitis,  705. 
Ball's    method    of     radical    cure    of 

hernia,  625. 
Bands,    strangulation    by,    595,    601, 

604. 
Banks'  operation  for  hernia,  623. 
Barker's   method    of    radical  cure   of 

hernia,  625. 
Base  of  skull,  fracture  of,  333. 
Bassini's   method    of  radical    cure   of 

hernia,  626. 
Battey's  operation,  75 S. 
Bedsores  in  spinal  injuries,  366. 
Bellocq's  sound,  542. 
Biceps  tendon,  rupture  of,  196,  403. 
Bigelow's  classification  of  dislocation 
of  hip,  431, 

operation,  688. 
Bishop's    method    of   radical    cure  of 

hernia,  624. 
Black-eye,  349. 
Bladder,  aspiration  of,  727. 

atony  of,  681. 

calculus  of,  674,  677,  684,  697. 

cancer  of,  683. 

diseases  of,  678. 

extroversion  of,  678. 

foreign  bodies  in,  400,  402. 


Bladder,  inflammation  of,  679. 

irritability  of,  681. 

malformations  of,  679. 

paralysis  of,  6S1. 

puncture  of,  727. 

rupture  of,  396. 

sacculated,  701,  708. 

in  spinal  injuries,  366. 

stone  in,  684,  697. 

in  stricture,  707. 

tubercular  disease  of,  683. 

tumors  of,  683. 
Bleeding,  22. 
Blepharospasm,  486. 
Blood,  transfusion  of,  125. 
Blood-tumors  of  scalp,  327. 
Blood-vessels,  diseases  of,  267,  302. 

injuries  of,  198,  203,  372. 
Boils,  322. 
Bone,  abscess  of,  223. 

atrophy  of,  225. 

cancer  of,  235. 

caries  of,  216. 

cysts  in,  236. 

diseases  of,  209. 

fracture  of,  168. 

hypertrophy  of,  225. 

inflammation  of,  209. 

injuries  of,  168. 

mollities  ossium,  22S. 

necrosis  of,  218. 

pulsatile  tumors  of,  236, 

rickets  in,  226. 

sarcoma  of,  233. 

sclerosis  of,  214,  216. 

suppuration  in,  223. 

syphilis  of,  225. 

tubercle  of,  225. 

tumors  of,  230. 

ulceration  of,  216. 
Bone-plates,  389. 
Bow-legs,  775. 
Bowel  {see  Intestines). 
Box  splint,  460. 
Brachial  artery,  aneurysm  of,  289. 

ligature  of,  296. 
Brain,  abscess  of,  344,  464,  478. 

compression  of,  337. 

concussion  of,  336. 

contusion  of,  341. 

extravasation  of  blood  on,  339. 

injuries  of,  336. 

inflammation  of,  344. 

irritation  of,  342. 

hernia  of,  346. 


796 


INDEX. 


Brain,  laceration  of,  341. 

suppuration  in,  344. 

surgerj',  464. 

topography  of,  342. 

tumors  of,  464. 
Brasdor's  operation,  282,  285. 
Breast,  abscess  of,  760. 

adenoma  of,  762. 

adeno-cystoma  of,  765. 

adeno-fibroma  of,  763. 

adeno-sarcoma  of,  763. 

cancer  of,  766,  770. 

cysts  of,  766,  770. 

chronic     mammary     glandular 
tumor  of,  762. 

diseases  of,  759. 

excision  of,  771. 

galactocele  in,  766. 

hypertrophy  of,  762. 

inflammation  of,  759. 

lobular  induration  of,  761. 

neuralgia  of,  759. 

sarcoma  of,  764. 

tumors  of,  762. 
Bronchocele,  577. 
Bruises,  119. 
Bryant's  line,  431. 

splint,  450. 
Bubo,  67,  706. 
Buchanan's  operation,  782. 
Bunion,  266. 
Burns  and  scalds,  120. 

degrees  oi,  120. 

treatment  of,  122. 
Bursoe,  diseases  of,  255. 

patellae,  267. 

semi-membranosus,  267. 
Bursal  cysts,  517. 
Bursitis,  266. 

C^ALCULUS  of  bladder,  674,  684. 
^        in  female  bladder,  697. 

of  kidney,  670. 

of  prostate,  702. 

salivary,  517. 

in  urethra,  722. 

urinary,  674. 
Calculous  ijyclitis,  670. 
Callaway's  test  for  dislocated  shoulder, 

406. 
Callisen's  operation,  6J2. 
Callous  ulcers,  49. 
Callus,  171. 

Cancellous  exostoses,  230. 
Cancer  (see  Carcinoma). 


Cancrum  oris,  516. 
Carbuncle,  323. 
Carcinoma,  92. 

acinous,  93. 

adenoid,  97. 

of  bladder,  683. 

of  breast,  766,  770. 

of  bone,  235. 

colloid,  95,  771. 

columnar-celled,  97. 

cylindrical,  97. 

dissemination  of,  93. 

encephaloid,  94. 

epithelial,  95. 

hard,  93. 

of  jaw,  536,  539. 

of  lip,  511. 

medullary,  94,  770. 

of  nose,  549. 

of  cesophagus,  557. 

of  penis.  732. 

of  rectum,  664. 

rodent,  514. 

scirrhous,  93,  767. 

of  scrotum,  736. 

soft,  94. 

spheroidal-celled,  93. 

of  squamous-celled,  95. 

of  testicle,  746. 

of  tongue,  522. 

of  tonsil,  532. 

treatment  of,  97. 

varieties  of,  93. 

of  vulva,  750. 
Carden's  amputation,  786. 
Caries,  216. 

of  skull,  462. 

of  vertebrce,  584. 
Carotid  aneurysm,  288. 

artery,  ligature  of,  293,  294. 
Carpus,  dislocation  of,  416. 

fracture  of,  428. 
Cartilaginous  tumors,  82,  232. 
Castration,  748. 
Cataract,  496. 
Catarrh,  chronic  nasal,  543. 

of  bladder,  680. 

of  ear,  474,  479. 

coudc,  701,  702. 
Catheters,  passage  of,  709. 

of  I'^ustachian,  469, 
Cautery,  in  hremorrhage,  130. 
Cavernous  angioma,  309. 
Cellulitis,  172. 
Cephalalgia,  trciihining  in,  467. 


INDEX. 


797 


Cephalhsematoma,  327. 

Cerebral  convolutions,  342,  465,  466. 

Cerebro-spinal  fluid,  335. 

Cerumen  in  ear,  472. 

Cervical  vertebrEe,  disease  of,  590. 

Chalazion,  485. 

Chancre,  66,  730. 

Charbon,  15c. 

Charcot's  joint  disease,  251. 

Cheeks,  diseases  of,  509. 

Chemiotaxis,  26. 

Chemosis,  488. 

Chest,  contusions  of,  368. 

injuries  of,  368. 

operations  on,  374. 

wounds  of,  370. 
Chilblains,  321. 
Cholecystectomy,  615. 
Cholecysto-enterostomy,  615. 
Cholecystotomy,  615. 
Chopart's  amputation,  790. 
Chordee,  705. 
Choroiditis,  494. 
Cicatrices,  diseases  of,  119. 
Ciliary  blepharitis,  4S5. 
Ciliary  body,  inflammation  of,  494. 
Circular  enterorrhaphy,  383. 
Circumcision,  729. 
Cirsoid  aneurysm,  310. 
Clavicle,  dislocation  of,  404. 

fracture  of,  417. 
Clavus,  320. 
Cleft  palate,  527. 
Cline's  splints,  458. 
Cloacje  in  bone,  220. 
Clove-hitrh,  410. 
Club-foot,  775. 

Cock's  operation  for  stricture,  719. 
Cold  in  inflammation,  30. 

heemorrhage,   129. 
Colectomy,  611. 
Colibacillosis,  598. 
Collapse  {see  Shock). 
Colles'  fracture,  426. 

law,  76. 
Colloid  cancer,  95,  771. 
Coloboma,  486,  493. 
Colotomy,  611,  612. 
Comminuted  fracture,  itg. 
Common  carotid  artery,    ligature    of, 

293- 
Compound  dislocation,  191. 

fracture,  180. 
Compression  in  aneurysm,  278. 

of  brain,  337. 


Concussion  of  brain,  336. 

of  spinal  cord,  368. 
Condylomata,  69. 
Congenital  dislocations,  191. 

hernia,  643. 

syphilis,  73. 
Conical  cornea,  491. 
Conjunctiva,  diseases  of,  487. 

wounds  of,  490. 
Conjunctivitis,  487. 
Connective-tissue  tumors,  80. 
Continuous  suture,  112. 
Contraction,  Dupuytren's,  264.        * 
Contractions  in  intestinal  obstruction, 

597,  602,  605. 
Contrecoup,  fracture  by,  330. 
Contusions,  119. 

of  abdominal  wall,  376. 

of  arteries,  196. 

of  brain,  341. 

of  chest,  368. 

of  face,  348. 

of  joints,  186. 

of  larynx,  355. 

of  lungs,  370. 

of  muscles,  194. 

of  nerves,  208. 

of  scalp,  327. 
Convulsive  tic,  319. 
Cooper's  classification   of  dislocations 

of  the  hip,  431. 
Coracoid  process,  fracture  of,  420. 
Cord,  spina],  injuries  of,  363. 
Coredialysis,  493. 
Cornea,  diseases  of,  490. 
Corns,  320. 
Coronoid  process  of  jaw,  fracture    of, 

351- 

of  ulna,  fracture  of,  428. 

Coryza,  543. 

Cowperitis,  706. 

Cranial  nerves,  injuries  of,  335. 

Craniectomy,  467. 

Craniiitabes,  75. 

Cranium  {see  Skcll). 

Crepitus,  170. 

Croup,  562,  563. 

Crutch-palsy,  185. 

Crystalline  lens,  disease  of,  496. 

Curvature  of  spine,  angular,  584. 

lateral,  580. 
Cut  throat,  354. 
Cyclitis,  494. 
Cycloplegia,  509. 
Cylindrical  carcinoma,  97. 


798 


INDEX. 


Cystic  disease  of  breast,  766. 

kidney,  672 

ovary,  753. 

testis,  747. 

Cystitis,  acute,  679. 

chronic,  680. 
Cystitome,  498. 
Cystocele,  758. 
Cysts,  98. 

athermous,  99. 

blood,  100. 

in  bone,  236. 
•       congenital,  102. 

dentigerous,  536. 

dermoid,  102,  517. 

extravasation,  100. 

exudation,  98. 

hydatid,  loi. 

Meibomian,  485. 

milk,  765. 

mucous,  99. 

pancreatic,  619. 

parasitic,  loi. 

proliferous,  loO. 

retention,  98. 

sarcomatous,  91. 

sebaceous,  99. 

serous,  100,  766. 

DE  CARTE'S  tourniquet,  280. 
Deformities  of  nose,  550. 
Deformities  of  feet,  775. 
Delirium,  traumatic,  139. 

tremens.  139. 
Dentigerous  cysts,  536. 
Deposits,  urinary,  674. 
Depressed  fracture  of  skull,  330,  331. 
Dermoid  cysts,  102,  517. 
Diabetic  gangrene,  57. 
Diaphragmatic  hernia,  651. 
Diathesis,  strumous,  63. 

hccmorrhagic,  76. 
Diffused  aneurysm,  273. 
Dilatation  of  stricture,  71 1. 
Diphtheria,  laryngeal,  562. 
Diphtheria,  wound,  150. 
Dijilopia,  507. 

Direct  inguinal  hernia,  644,  646. 
Dislocations,  187. 

causes  of,  187. 

compound,  191. 

congenital,  191. 

extension  in,  190. 

manipulation  in,  189. 

special  (jf^  Special  Kkgions), 


Dislocations,  symptoms  of,  188. 

treatment  of,   189. 

unreduced,  iSS. 

varieties,  187. 
Dissecting  aneurysm,  273. 
Dissection  wounds,   117. 
Distal  ligature,  285. 
Dorsalis  pedis  artery,  ligature  of,  302. 
Dorsum  ilii,  dislocation  on,  431,  432. 
Double  inclined  plane,  451. 
Douche,  nasal,  545. 
Drainage  tube,  no. 
Drill-bone,  261. 
Dropsy  of  antrum,  536. 
Duct  cancer,  770. 

Dusas'  test  for  dislocation  of  hume- 
rus, 406. 
Dumb  rabies,  1 61. 
Duodenostomy,  618. 
Dupuytren's  contraction,  264,  265. 

sj^lint,  459. 
Dura  mater,  blood  beneath,  338. 

fungus  of,  464. 

inflammation  of,  344. 


F 


AR,    bleeding    from,   in    fractured 
_  skull,  334. 

catarrh  of,  474,  479. 

cerumen  in,  472. 

diseases  of,  468. 

examination  of,  468. 

foreign  bodies  in,  350. 

wax  in,  472. 
Ecthyma,  68. 
Ectopia  vesica;,  678. 
Ectropion,  486. 
Eczematous  ulcer,  49. 
Eczema  of  external  ear,  471. 
Elbow  joint,  dislocation  of,  413. 

excision  of,  257. 
Electric  stroke,  123. 
Electrolysis  in  nrevus,  310. 

in  stricture,  719. 
Elephantiasis  scroti,  733. 

of  the  labium,  750. 
Ellis'  method  of  treating  fracture   of 

the  clavicle,  419. 
Eml)olic  abscesses,  158.. 
Iunl)olism,  fat,  184. 
iMnnu'tropia,  505. 
Eni]ihyscma,  surgical,  373. 
I'jnproFthotonos,  166. 
iMicephalitis,  344. 
Enccplialocelc,  463. 
Encephaloid  cancer,  94, 


799 


Enchondroma,  82,  232. 
Encysted  hernia,  643,  644. 

hydrocele,  736. 
Endarteritis,  268. 
Endosteal  sarcoma,  233. 
Enterectomy,  610. 
Enteritis,  597. 
Enterocele,  621. 
Entero-epiplocele,  621. 
Enterotomy,  609. 
Entropion,  486. 
Enuresis,  697. 
Epicanthus,  486. 
Epididymitis,  741. 
Epiglottis,  wounds  of,  354. 
Epilepsy,  focal  467. 

trephining  in,  347. 
Epileptiform  neuralgia,  315. 
Epiphora,  486. 
Epiphyses,   separation    of,    180,    422, 

424,  427,  452. 
Epiphysitis,  242. 
Epiplocele,  621. 
Epiplo-enterocele,  621. 
Episcleritis,  492. 
Epispadias,  679. 
Epistaxis,  541. 
Epithelioma,  95. 

of  bone,  235. 

of  lips,  511. 

of  oesophagus,  557. 

of  penis,  731. 

of  rectum,  664. 

of  scrotum,  732. 

of  tongue,  522. 
Epulis,  533,  534. 
Erasion  of  joints,  256. 
Erysipelas,  144. 

cellular,  149. 

cellulo-cutaneous,  148. 

cutaneous,  146. 

phlegmonous,  148. 

simple,  146. 
Esmarch's  bandage  in  aneurysm,  281. 
Estlander's  operation,  375. 
Ethmoidal  sinuses,  catarrh  of,  553. 
Eustachian  catheter,  469. 
Excision  of  breast,  771. 

of  jaw,  538,  540. 

of  joints,  257. 

of  larynx,  575. 

of  rectum,  666. 

of  testicle,  748. 

of  tongue,  524. 
Exomphalos,  649. 


Exophthalmic  goitre,  5  78. 
Exostosis,  aural,  473. 

cancellous,  230. 

compact,  231. 
Extension  of  the  spine,  367. 
Extension  in  dislocation,  190. 

of  shoulder,  409. 
with  pulleys,  410. 
External   carotid   artery,   ligature    of, 

294. 
External  iliac  artery,  ligature  of,  298. 
Extra- capsular  fracture  of  femur,  446. 
of  humerus,  421. 
Extravasation  of  blood  in  brain,  339. 

of  urine,  721. 
Extroversion  of  bladder,  678. 
Eye,  diseases  of,  482. 

enucleation  of,  504. 

examination  of,  482. 
Eyelids,  diseases  of,  486. 

injuries  of,  349. 

FACE,  injuries  of,  348. 
Facial  artery,  ligature  of,  295. 
carbuncle,  510. 
Facultative  parasites,  25. 

saprophytes,  24. 
Fsecal  abscess,  631. 

fistula,  631. 
Faeces,  impaction  of,  594,  600,  603. 
Fallopian  tubes,  diseases  of,  757. 
False  joint,  175. 

passage,  710. 
Farcy,  160. 
Fascite,  diseases  of,  264. 

contractions  of,  264. 
Fat-embolism,  184. 
Fatty  tumor,  81. 
P'auces,  diseases  of,  527,  532. 
Feet,  deformities  of,  775. 
Female  genitals,  diseases  of,  749. 
injuries  of,  400. 
bladder,  stone  in,  697. 
Femoral  aneurysm,  291. 

artery,  ligature  of,  299. 
hernia,  646,  648. 
Femur,  dislocation  of,  429. 
fracture  of,  444. 

of  condyles  of,  451. 
of  neck  of,  444. 
of  shaft  of,  44S. 
of  trochanter  of,  448. 
separation  of  epiphyses  of,  448, 

452. 
Fever,  hectic,  42. 


8oo 


INDEX. 


Fever,  inflammatory,  27. 

traumatic,  simple,  138. 
septic,  142. 

urethral,  711. 
Fibro-cellular  tumors,  80. 
Fibroma,  80. 
Fibula,  fracture  of,  456. 
Filaria  sanguinis  hominis,  733. 
Fingers,  amputation  of,  7S8. 
First  intention,  union  by,  105,  106. 
Fissure  of  anus,  654. 
Fistula,  43. 

frecal,  631. 

in  ano,  660. 

recto-vaginal,  752. 

salivary,  350. 

urinary,  720. 

vesico-intestinal,  683. 

vesico- vaginal,  751. 
Fitzgerald's  operation,  782. 
Flap  amputations,  785. 
Flat-foot,  778,  784. 
Flexion  in  aneurysm,  281. 
Focal  epilepsy,  467. 
Follicular  pharyngitis,  554. 
Foot,  amputation  of,  789. 
Forceps,  artery,  1 31. 

aural,  468,  472. 

pharyngeal,  359. 

torsion,  132. 
Forcipressure  in  hemorrhage,  133. 
Forearm,  amputation  of,  787. 

fractures  of,  425. 
P"oreign  body  in  air-passages,  360, 

in  bladder,  400,  402. 

in  bronchi,  360. 

in  ear,  350. 

in  eye,  491. 

in  intestine,  594. 

in  larynx,  360. 

in  nerves,  208. 

in  nose,  349. 

in  oesophagus,  358. 

in  pharynx,  358. 

in  rectum,  399. 

in  trachea,  360. 

in  urethra,  400,  402. 

in  vagina,  400. 
Fractures,  i68. 

causes  of,  168. 

combined  with  dislocation,  184. 

complications  of,  183. 

compound,  180. 

crejiitus  in,  169. 

with  dislocation,  184. 


Fractures,  general  pathology  of,  168. 

greenstick,  169,  425. 

implicating  a  joint,  184. 

malunited,  179. 

reduction  of,  172. 

signs  of,  169. 

special  (si-e  Regions). 

treatment  of,  172. 

union  of,  170. 

ununited,  175. 

varieties  of,  168. 

vicious  union  of,  179. 
Fragments,  fixation  of,  177. 
Freund's  operation,  758. 
Frontal  sinus,  catarrh  of,  553. 
Fnngating  caries,  217. 
Fungus  of  dura  mater,  464. 
Furneaux  Jordan's  operation,  7S8. 
Furuncles  of  meatus,  472. 
Furunculus,  322. 
Fusiform  aneurysm,  273. 

GAG,  Smith's,  528. 
■     Galactocele,  766. 
Gall-bladder,  draining  the,  615. 

extirpation  of,  615. 

rupture  of,  378. 

stones,  passage  of,  594,  601,604, 

vv'ound  of,  381. 
Ganglion,  262. 
Gangrene,  51. 

causes  of,  53. 

diabetic,  57. 

dry,  53- 

from  constriction,  185. 

from  ergot,  54. 

from  obliteration  of  artery,  55. 

hospital,  149. 

line  of  demarcation  in,  52. 

minute  changes  in,  52. 

moist,  53. 

Raynaud's,  58. 

senile,  56. 

signs  of,  54. 

spreading,  56. 

symmetrical,  58. 

traumatic,  55. 

treatment  of,  54.. 

of  bowels  in  henna,  630. 

varieties  of,  55. 
Gastro-enterostomy,  616. 
Gastrostomy,  559. 
Gastrotomy,  558. 

(jeneral  paralysis,  trephining  in,  467. 
Genital  organs,  diseases  of,  728. 


INDEX. 


Soi 


Genital  organs,  injuries  of,  402. 

female,  diseases  of,  749. 
injuries  of,  400. 
Genu  recurvatum,  775. 

valgum,  773. 

varum,  775. 
Gland  disease,  strumous,  312. 
Glanders,  159. 
Glandular  tumor,  91. 
Glaucoma,  502. 
Gleet,  704. 

Glenoid  cavity,  fracture  of,  420. 
Glioma  of  the  retina,  501. 
Glio-sarcoma,  88. 
Glossitis,  519. 
Glottis,  cedema  of,  562. 

scalds  of,  357. 
Gluteal  aneurysm,  290. 
Goitre,  577. 

acute,  579. 
Gonococcus,  704. 
Gonorrhoea,  703. 

complications  of,  705. 
Gonorrhoea!  ophthalmia,  488. 
Gordon's  splints,  427. 
Gouty  ulcers,  51. 
Graft,  omental,  389. 
Granular  pharyngitis,  554. 
Grattan's  osteoclast,  782. 
Greenstick  fracture,  169,  417,  425. 
Gumboil,  533. 
Gummata,  70,  261. 
Gums,  diseases  of,  533. 
Greig  Smith's  method  of  radical  cure 

of  hernia,  628. 
Gruber's  artificial  drum,  476. 

H^MARTHROSTS,  186. 
Hematocele,  739. 
Hremato-kolp'os,  752. 

-metra,  752. 

-salpinx,  752,  757. 
Hematoma,  ico. 

auris,  471. 

of  labium,  400. 

of  scalp,  327. 
Heematopncea,  371. 
Hoematosalpinx,  75^. 
Hasmaturia,  698. 
Hoemcj^hilia,  76. 
Hcemothorax,  373. 
Hemorrhage,  123. 

arterial,  126. 

capillary,  136. 

effects  of,  124. 


Haemorrhage,  infusion  of  saline  solu- 
tion in,  125 

intermediary,  133. 

internal,  124. 

ligature  in,  131. 

natural  arrest  of,  126. 

parenchymatous,  124. 

primary,  126. 

reactionary,  133. 

recurrent,  133. 

secondary,  134. 

surgical,  arrest  of,  128. 

torsion  in,  132. 

transfusion  in,  125. 

treatment  of,  124,  128. 

venous,  136. 
Hsemorrhagic  diathesis,  76. 
Haemorrhoids,  656. 
Hallux  dolorosus,  779. 

valgus,  784. 
Halsted's  method  for  radical  cure  of 

hernia,  625. 
Hamilton's  test  for  dislocated  shoul- 
der, 406. 
Hammer  toe,  784. 
Hand,  amputation  of,  787. 

injuries  of,  404. 
Hare-lip,  511. 
Hare-lip  pin,  112. 
Hart's  method  of  flexion,  281. 
Head,  injuries  of,  327. 
Healing  by  first  intention,  104,  105. 

by  granulation,  105,  108. 

by  second  intention,  105,  108. 

process  of,  104. 

by  third  intention,  106,  109. 

under  a  scab,  106,  109. 
Heart,  injuries  of,  371. 
Heat  in  haemorrhage,  130. 
in  inflammation,  31. 
Hectic  fever,  42. 
Hernia,  619. 

causes  of,  620. 

cerebri,  346. 

congenital,  643. 

diaphragmatic,  651. 

femoral,  646,  648. 

incarcerated,  640. 

infantile,  644. 

inflamed,  640. 

inguinal,  642,  643. 

into  funicular  process,  643. 

internal,  595. 

irreducible,  627. 

ischiatic,  652. 


So: 


INDEX. 


Hernia,  labial,  642. 

knife.  Cooper's,  634. 

Littre's,  630. 

lumbar,  6 '■,2. 

of  lung,  374. 

obstructed,  640. 

obturator,  650. 

perineal,  652. 

phrenic,  651. 

pudendal,  652. 

radical  cure  of,  623. 

rarer  forms  of,  652. 

reducible,  621. 

reduction  of,  622. 

Richter's,  630. 

sac  of,  621. 

scrutal,  642. 

strangulated,  629. 

taxis  in,  632. 

of  lung,  374. 

of  testis,  748. 

umbilical,  649. 

ventral,  652. 
Herniotomy,  633. 
Herpes  of  the  lip,  509. 
Hey's  amputation,  791. 
Hilton's  method    of  opening   an  ab- 
scess, 40. 
Hip,  tubercular  disease  of,  246. 
Hip-joint,  amputation  at,  7S8. 

disease  of,  246. 

dislocation  of,  429,  433,  436. 

excision  of,  258. 
His's  duct,  remains  of,  518. 
Histrionic  spasm,  319. 
Hodgkin's  disease,  313. 
Holt's  operation,  713. 
Hordeolum,  486. 
Horny  growths,  99. 
Hospital  gangrene,  149. 
Housemaid's  knee,  266. 
Howse's    method    of    suture   in   gas- 

trosotomy,  559. 
Humerus,  dislocation  of,  406. 

fracture  of,  420,  422,  423. 
Hunter's  operation,  282. 
Hutchinson's  lines,  74. 
Hyalitis,  502. 
Hydatid  cyst,  10 1. 
Hydrenccphaloccle,  463. 
Hydrocele,  734. 

congenital,  736. 

of  cord,  737. 

encysted,  736. 

infantile,  736. 


Hydrocele  of  the  spermatic  cord,  737. 
Hydrocephalus,  467. 
Hydronephrosis,  669. 
Hydrophobia,  160. 
Hydrops  articuli,  238. 
Hydrosalpinx,  757. 
Hymen,  imperforate,  752. 
Hyoid  bone,  dislocation  of,  356. 

fracture  of,  356. 
Hypermetropia,  506. 
Hypertrophy  of  bone,  225. 

of  breast,  761. 

of  muscle,  261. 

of  prostate,  7CO. 

of  toe-nail,  326. 

of  tonsil,  531. 
Hyphcema,  493. 
Hypopyon,  490. 
Hysterectomy,  758. 

ICHTHYOSIS  of  tongue,  519. 
1^      Iliac  arteries,  ligature  of,  298,  299. 
Impaction  of  fccces,  594,  600,  603. 
Imperforate  anus,  652. 

hymen,   752. 
Impermeable  stricture,  707,  71 1. 
Incarcerated  hernia,  640. 
Incontinence  of  urine,  697. 
Infantile  hernia,  644. 

hydrocele,  736. 

syphilis,  73. 
Infective  processes  in  wounds,  diseases 

due  to,  141,  144. 
Inflammation,  17. 

acute,  17. 

causes  of,  21. 

chronic,  33. 
Inflammation,  fever  in,  27. 

infective,  29. 

micro-organisms  in,  23. 

minute  changes  in,  19. 

process  of,  1 7. 

septic,  28. 

signs  and  symptoms  of,  26. 

terminations  of,  17,  21. 

theory  of,  21. 

treatment  of,  29. 

varieties  of,  28. 
Inflammatory  delirium,  139. 

fever,  27,  28. 
Infusion  of  saline  solution  in  haemor- 
rhage, 125. 
Ingrowing  toe-nail,  326. 
Inguinal  aneurysm,  290. 

colotomy,  611. 


INDEX. 


803 


Inguinal  hernia,  642,  644 
Injuries,  general  pathology  of,  104. 
Insect  stings,  118. 
Intention,  union  by  first,  105,  106. 

second,   105,  108. 
Intercostal  artery,  wounds  of,  372. 
Intermediary  hcemorrhage,  133. 
Internal  cartoid  artery,  ligature  of,  294. 

strangulation,  595,  601,  604. 

urethrotomy,  713. 
Interrupted  suture,  112. 
Intestinal  anastomosis,  3S7. 

obstruction,  594. 
Intestine,  short-circuiting  the,  608. 
Intestines,  surgical  diseases  of,  594. 

foreign  bodies  in,  594. 

malformation  of,  598. 

rupture  of,  378. 

strangulation  of,  595,  601,  604. 

stricture  of,  597,  601,  605. 
Intestines,  suture  of,  382. 

wounds  of,  381. 
Intracapsular  fracture  of  femur,  444. 

humerus,  421. 
Intracoracoid  dislocation,  408. 
Intracranial  hcemorrhage,  339. 

inflammation,  344. 

suppuration,  346,  478. 
Intraocular  tension,  485. 
Intubation  of  larynx,  575. 
Intussusception,  595,  596,  601,  604. 
Iridectomy,  493. 
Irideremia,  493. 
Iris,  disease  of,  492. 

wounds  of,  493. 
Iritis,  492. 

serous,  495. 

quiet,  493. 

syphilitic,  69,  492. 
Irreducible  hernia,  627. 
Irritable  bladder,  681. 

ulcer,  50. 
Ischiatic  hernia,  652. 
Ischio-rectal  abscess,  660. 
Ivory  exostosis,  231,  473. 

TACKSONIAN    epilepsy,  in    tumor 
I      of  brain,  465. 
-J  Jaw,  abscess  of  533,  534. 

closure  of,  534. 

diseases  of,  533. 

dislocation  of,  352. 

excision  of,  538,  540. 

fracture  of,  351. 

necrosis  of,  535, 


Jaw,  subluxation  of,  353. 

tumors  of,  536,  539. 
Jejunostomy,  618. 
Joints,  ankylosis  of,  254. 

Charcot's  disease  of,  251. 

contusions  of,  186. 

diseases  of,  236. 

dislocations  of,  187. 

erasion  of,  256. 

excision  of,  256. 

injuries  of,  186. 

loose  bodies  in,  252. 

neuralgia  of,  255. 

resection  of,  256. 

rheumatoid  arthritis  of,  249. 

sprains  of,  186,  403. 

stiff,  254. 

tubercular  disease  of,  243. 

wounds  of,  192. 

Y  ELOTOMY,  633. 
XV     Keratitis,  490. 
Keratoconus,  491. 
Kidney,  abscess  of,  668. 

aspiration  of,  672. 
Kidney,  calculus  of,  670. 

cysts  of,  672. 

excision  of,  673. 

inflammation  of,  667. 

operations  on,  672. 

rupture  of,  378. 

surgical  diseases  of,  667. 

tuberculous,  671. 

tumors  of,  672. 
Kocher's  method  of  excising  tongue, 

526. 
Knee,  dislocations  of,  440. 

excision  of,  259. 

sprains  of,  429. 
Knock-knee,  773. 
Kraske's  operation,  666. 
Kyphosis,  583. 

IABIUM,  abscess  of,  750. 
^        adhesion  of,  749. 
cysts  of,  756. 
elephantiasis  of,  750. 
epithelioma  of,  750. 
hsematoma  of,  400. 
tumors  of,  750 
I  Laborde  method  of  treating  asphyxia, 
123. 
Laceration  of  brain,  341 
Lachrymal  abscess,  487. 

apparatus,  disease  of,  486. 


So4 


INDEX. 


Laminectomy,  590. 

Langenbeck's    operation,     257,    538, 

539- 
Laparotomy,  605. 
Lardaceous  disease,  43. 
Laryngectomy,  575. 
Laryngitis,  560. 

acute,  560. 

chronic,  561. 

membraneous,  562. 

cedematous,   562. 
I-aryngoscope,  method  of  using,  561. 
Laryngotomy,  566,  572,  573. 
Laryngo-tracheotomy,  566,  573. 
Larynx,  contusion  of,  355. 

disease  of,  560. 

examination  of,  560. 

extirpation  of,  575. 

foreign  bodies  in,  360, 

fractures  of,  356. 

inflammation  of,  560. 

injuries  of,  355. 

intubation  of,  566,  575. 

syphilis  of,  565. 

tubercle  of,  564. 

tumors  of,  565. 
Lateral  curvature  of  spine,  580. 
Lateral  lithotomy.  691. 
Lateral  sinus,  trephining,  478. 
Legs,  amputation  of,  789. 

fracture  of  bones  of,  444. 
Lambert's  suture,  382,  397. 
Lens,  diseases  of,  496. 
Leptomeningitis,  344. 
Leucoplakia,  520. 
Ligature  in  aneurysm,  281. 

of  arteries,  131,  199,  292. 

dangers  of,  283. 

distal,  285. 

double,  286. 

gangrene  after,  283. 

in  hemorrhage,  131. 

Ilunterian,  282. 

rules  for,  292. 

secondary    hix;morrhage    after, 
134,  283. 
lyightning  stroke,  123. 
Linear  proctotomy,  664. 
Lines  of  incision  in  alxlominal  oper- 
ations, 606. 
Lingual  artery,  ligature  of,  295. 
I-ipoma,  81. 

nasi,  541. 
Lips,  adenoma  of,  510. 

carbuncle  of,  510. 


Lips,  chancre  of,  511. 

diagnosis  of,  511, 

cysts  of,  510. 

diseases  of,  509. 

epithelioma  of,  51 1. 

fissures  of,  510. 

herpes  of,  509. 

hypertrophy,  510. 

malformations  of,  5 1 1. 

nsevus  of,  510. 

tumors  of,  511. 

ulcers  of,  510. 
Lisfranc's  amputation,  791. 
Lister's  abdominal  tourniquet,  2S0. 

excision  of  wrist,  258. 
Liston's  splint,  449. 
Lithic  acid  deposit,  674. 
Litholapaxy,  688. 
Lithotomy,  691. 

lateral,  691. 

median,  696. 

supra-pubic,  696. 
Lithotrity,  688. 
Littre's  operation,  61 1. 
Liver,  aspiration  of,  613. 

incision  of,  614. 

rupture  of,  377. 

wound  of,  381. 
Loose  bodies  in  bursje,  266. 
in  ganglia,  262. 
in  joints,  252. 
Lordosis,  584. 
Loreta's  operation,  618. 
Lower  extremity,  injuries  of,  429. 
Luer's  forceps,  131. 
Lumbar  abscess,  586. 

colotomy,  612. 
Lung,  contusion  of,  370. 

hernia  of,  374. 

])rolapse  of,  374. 

wounds  of,  370. 
Lupus  erythematosus,  325. 

vulgaris,  324. 
Lymph-scrotum,  733. 
Lymphadenitis,  31 1. 
Lymphadenoma,  86,  313. 
Lymjihangiectasis,  31 1. 
I.ym])hangionia,  86. 
Lymphangitis,  310,  706. 
Lym])hatic  fistula,  311. 

varix,  31 1. 
Lym]ihalics,  diseases  of,  310. 
Lymphorrhfoa,  31 1. 
Lympho-sarcoma,  88,  314. 


INDEX. 


805 


IV  TACEWEN'S  operation,  286,  624. 

IVl      Macroglossia,  519. 

Malgaigne's  hooks,  453. 

Malignant  pustule,  150. 

Malunited  fracture,  179. 

Mammary  gland  {see  Breast). 

Manipulation  in  aneurysm,  286. 
in  dislocations,  189. 
of  hip,  435. 
of  shoulder,  409. 

Manning's  splint,  454. 

Mastitis,  761. 

Mastoid,  disease,  477. 

Maunsell's  method  of  uniting  divided 
intestine,  384. 

Mayo  Robson's  treatment  of  fracture 
of  patella,  454. 

Mayo    Robson's   treatment    of  spina 
bifida,  594. 

McBurney's  method  of  radical  cure  of 
hernia,  626. 

Meatus,  diseases  of,  471. 

Meckel's  ganglion,  excision  of,  317. 

Median  lithotomy,  696. 

Medio-tarsal  amputation,  790. 

Medullary  cancer,  94. 

Meibomian  cyst,  485. 

Melanotic  sarcoma,  88. 

Membrana    tympani,    appearance    of, 
468. 
artificial,  475. 
perforation  of,  475. 

Membraneous  laryngitis,  562. 

Meniere's  disease,  480. 

Meningeal  artery,  rupture  of,  339. 

Meningitis,  344. 

in  ear  disease,  477. 

Meningocele,  463. 
spinal,  591. 

Meningo-encephalitis,  344. 
-myelocele,  591. 

Mercurial  teeth,  75. 

Metacarpus,  dislocation  of,  416. 
fracture  of,  428. 

Metastatic  abscess,  157. 

Metatarsal  bones,  fracture  of,  461. 

Microcephaly,  467. 

Micrococci,  24,  38. 

Micrococcus,  gonorrhoeal,  704. 

Micro-organisms,  24,  38. 

Mikulicz's  operation  for  remoying  thy- 
roid gland,  579. 

Milk  cysts,  766. 

Mixed  sarcoma,  91. 

Mollities  ossium,  228. 


Molluscum  fibrosum,  81. 
Morbus  coxEe  {see  Hip  Disease). 
Morton's  fluid,  594. 
Morrant  Baker's  cysts,  238. 
Mortification,  51. 
Mouth,  diseases  of,  509. 
Mucocele,  487. 
Mucous  cysts,  99. 

membranes,  syphilitic  affections 
of,  69. 

tubercles,  69. 

tumors  {see  Myxoma). 
Mulberry  calculus,  677. 
^Multiple  exostoses,  231. 
Mumps,  576. 
Murphy's  button,  390. 

method  of  uniting  intestine, 
390,  616,  617. 
Muscles,  abscess  of,  260. 

atrophy  of,  261. 

contusions  of,  194. 

degeneration  of,  261. 

diseases  of,  260. 

gummata  in,  261. 

hypertrophy  of,  261. 

inflammation  of,  260. 

injuries  of,  194. 

ossification  of,  261. 

rupture  of,  195,  403,  429.     " 

sprains  of,  403,  429. 

tumors  of,  261. 

wounds  of,  194. 
Muscle  tumors,  85. 
Muscular  tic,  319. 
Mydriasis,  4S3. 
Myeloid  sarcoma,  90. 
Myo-fibroma,  86. 
Myoma,  85. 
Myopia,  506. 
Myositis,  260. 
Myxoma,  S3. 

N^VUS,  308. 
capillary,  308. 

venous,  309. 
Nails,  diseases  of,  326. 

ingrowing,  326. 
Nares,  plugging  the,  542. 
Nasal  bones,  fracture  of,  350. 

catarrh,  543._ 

cavity,  examination  of,  543. 

douche,  545. 

polypi,  547. 

specula,  543. 

spray,  545. 


8o6 


INDEX. 


Xasal  tumors,  548,  551. 
Naso-pharyngeal  tumors,  548. 
Natiform  skull,  75. 
Neck,  injuries  of,  354. 
wounds  of,  354. 
Necrobiosis,  52. 
Necrosis,  218. 

central,  213. 

in  ear  disease,  477. 

of  jaw,  535. 

of  nasal  bones,  546,  549. 

phosphorus,  535. 

quiet,  222. 

of  skull,  462. 
Needle  in  palm,  404. 

holder,  1 12. 
Needles,  palate,  529. 

Smith's,  528. 

surgical,  1 12. 
Nelaton's  line,  431,  433. 

splint,  427. 

operation,  549,  609. 
Nephrectomy,  673. 
Nephritis,  667. 

simple  interstitial,  667. 

suppurative  or  septic,  668. 
Nephro-lithotoniy,  673. 
Nephrorrhaphy,  674. 
Nephrotomy,  673. 
Nerve-grafcing,  207. 

stretching,  316, 

suturing,  206. 
Nerves,  compression  of,  208. 

contusion  of,  208. 

degeneration  of,  205. 

diseases  of,  314. 

foreign  bodies  in,  208. 

injuries  of,  204. 

rupture  of,  207. 

transplantation  of,  207. 

tumors  of,  318. 

wounds  of,  204. 
Nervous  traumatic  delirium,  139. 
Neuralgia,  314. 

of  breast,  759. 

epileptiform,  315. 

of  joints,  255. 
-of  testicle,  748. 
Neurectomy,  316. 
Neuritis,  314. 

retro-bulbar,  500. 
Neuroma,  319. 
Neurotomy,  316. 
Nicalodoni's  (jpcration,  784. 
Nipple,  Pagct's  disease  of,  759. 


Nodes,  211. 
Noma,  750. 
Nose,  diseases  of,  540. 

foreign  bodies  in,  349. 

fracture  of  bones  of,  350. 

polypus  of,  547. 
Nothnagel's  test,  383. 
Nystagmus,  509. 

OBLIQUE    inguinal    hernia,    642, 
646. 
Obstructed  hernia,  640 
Obturator   foramen,  dislocation   into, 

434- 
Obturator  hernia,  650. 
Occipito-atloid  disease,  590. 
Ocular  paralysis,  509, 
CEdema  glottidis,  562, 

solid,  303. 
QEsophagotomy,  362. 
CEsophagus,  cancer  of,  557. 

diseases  of,  555. 

foreign  bodies  in,  357. 

injuries  of,  357. 

pouches  of,  555. 

rupture  of,  357. 

stricture  of,  555. 

wounds  of,  357. 
Ogston's  operation,  784. 
Olecranon,  fracture  of,  427. 
Omental  graft,  389. 
Omphalocele,  649. 
Onychia,  321. 
Oiiphorectomy,  758. 
Operations,  treatment  of   patient  be- 
fore and  after,  114,  115. 
Ophthalmia,  487. 

cattarrhal,  487, 

gonorrheal,  488. 

granular,  489. 

membraneous,  488. 

muco-puruknt,  487. 

neonatorum,  488. 

phlyctenular,  489 
Ophthalmoplegia  externa,  509. 
Ophthalmoscope,  483. 
Opisthotonos,  166. 
Optic  nerve,  diseases  of,  499. 

neuritis,  499. 
Orbit,  diseases  of,  504. 
Orbital  aneurysm,  288. 
Orchitis,  simple,  741. 

strumous,  743. 

syphilitic,  744. 

tubercular,  743. 


INDEX. 


807 


Orthopaedic  surgery,  774. 
Os  calcis,  fracture  of,  460. 
Osseous  tumors,  83,  231. 
Osteitis,  214. 
Osteo-arthritis,  249. 

-malacia,  228. 

myelitis,  212. 

-porosis,  75. 

sarcoma,  233. 

sclerosis,  214. 
Osteoclasia,  774. 
Osteoma,  83,  230. 
Osteophytes,  250. 
Osteoplastic  osteitis,  216. 
Osteotomy,  774. 
Otomycosis,  473. 
Otorrhoea,  474. 
Ovarian  dropsy,  754. 

tumors,  753. 
Ovaries,  diseases  of,  753. 
Ovariotomy,  755. 
Oxalate  of  lime  calculi,  677. 

deposits,  676. 
OzEena,  549. 

PACHYMENINGITIS,  344,  586. 
Paget's  disease  of  nipple,  759. 
Painful      subcutaneous     tumors,     81, 

319- 
Palate,  cleft,  527,  530. 

diseases  of,  527. 

operation  for  closure  of,  528. 
Palm,  needle  in  the,  404. 

wounds  of,  403. 
Palmar  arch,  wounds  of,  403. 

fascia,  contraction  of,  264. 
Pancreatic  cyst,  drainage  of,  619. 
Pannus,  490. 
Panophthalmitis,  494. 
Papillitis,  499. 
Papilloma,  84. 
Papillo-retinitis,  500. 
Paracentesis  abdominis,  614. 

of  pericardium,  375. 

of  pleura,  374. 
Paralysis  of  third  nerve,  335, 
Paraphimosis,  728. 
Parasitic  bacteria,  25. 
Parker's  cannula,  569. 
Paronychia  tendinosa,  263. 
Parosteal  sarcoma,  233. 
Parotid  gland,  diseases  of,  576. 

tumors  of,  576. 
Parotitis,  576. 
Parrot's  nodes,  75. 


Pasteur's   treatment    of  hydrophobia, 

163. 
Patella,  bursa  over,  266. 

dislocation  of,  439. 

fracture  of,  452,  453. 
Patellar  ligament,  shortening  of,  441. 
Pathogenic  bacteria,  25. 
Paul's  method  of  uniting  divided  in- 
testine, 386. 

tubes,  607. 
Pelvis,  fracture  of,  394. 

injuries  of,  394. 
Pemphigus,  68. 
Penetrating  wounds  of  abdomen,  379. 

chest,  370. 
Penis,  amputation  of,  732. 

diseases  of,  728. 

epithelioma  of,  731. 

injuries  of,  402. 

ligature  of,  402. 

venereal  sores  on,  730. 
Perforating  ulcer  of  foot,  319. 
Pericardium,  incision  of,  375. 

injuries  of,  371. 

tapping,  375. 
Perineal  abscess,  719. 

fistula,  720. 

hernia,  652. 

section,  717,  718,  719. 
Perinephritic  abscess,  668. 
Perineum,  rupture  of,  400. 
Periosteal  abscess,  210. 

node,  211. 

sarcoma,  233. 
Periostitis,  209. 

acute,  209. 

chronic,  211. 

diffuse,  210. 

infective,  210. 

simple,  210. 
Periprostatic  abscess,  700. 
Peritoneum,  inflammation  of,  393. 

injuries  of,  376. 

laceration  of,  376. 
Peritonitis,  597,  602. 

traumatic,  393. 
Peritomy,  490. 
Perityphhtis,  597,  602,  605. 
Phagedcena,  149. 
Phagedcenic  chancre,  731. 

ulcer,  48. 
Phagocytosis,  26. 
Phalanges,  dislocation  of,  416. 

fracture  of,  428,  461. 
Pharyngeal  abscess,  554. 


8o8 


INDEX. 


Pharyngitis,  554. 
Pharyngotomy,  362. 
Pharynx,  burns  of,  357. 

diseases  of,  554. 

foreign  bodies  in,  358. 

injuries  of,  357. 

stenosis  of,  554. 

tumors  of,  555. 
Phelps'  operation,  7S2. 
Phimosis,  729. 
Phlebitis,  304. 

adhesive,  304. 

suppurative,  305. 

in  ear  disease,  478. 
Phleboliths,  303. 
Phlebotomy,  32. 
Phlegmasia  dolens,  303. 
Plilegmonous  erysipelas,  148. 
Phlyctenular  conjunctivitis,  4S9. 
Phosphatic  calculi,  678. 

deposits,  676. 
Phosphorus-necrosis,  535. 
Phrenic  hernia,  651. 
Piles,  656. 
Pinguecula,  489. 
Pirogoff's  amputation,  790. 
Plane,  double  inclined,  451. 
Plantaris  muscle,  rupture  of,  429. 
Pleura,  incision  of,  374. 

injury  of,  370. 

tapping,  374, 
Pleurosthotonos,  166. 
Plexiform  angioma,  308. 
Pneumonectomy,  375. 
Pneumothorax,  373. 
Pneumotomy,  375. 
Poisoned  vvountls,  1 17. 
Politzer's  bag,  469. 
Polyarticular  rheumatism,  249. 
Polycoria,  493. 
Polypus,  aural,  476. 

of  bladder,  683. 

of  nose,  547. 

of  rectum,  663. 

snare,  47(j. 
Poijliteal  aneurysm,  285,  291. 

artery,  ligature  of,  301. 
Port-wine  marks,  309. 
Post-mortem  wounds,  117. 
Post-pharyngeal  abscess,  554. 
Postnikow's  operation,  618. 
Pott's  disease  of  spine,  5X4. 

fracture,  456,  458,  459. 

puffy  tumor,  329. 


Pouches  of  cesophagus,  555. 
Prepuce,  dilatation  of,  730. 

operations  on,  728, 

slitting  of,  729. 
Presbyopia,  507. 
Pressure  in  haemorrhage,  130. 

in  aneurysm,  278. 
Priapism,  365. 

Primary  union  of  wounds,  106. 
Prolapse  of  lung,  374. 

of  rectum,  655. 
Proptosis,  504. 
Prostate,  abscess  of,  700. 

calculi  of,  7c 2. 

diseases  of,  699. 

enlargement  of,  700. 

inflammation  of,  699. 

malignant  disease  of,  702. 

retention  of  urine  in  enlarged, 

725- 

tubercle  ol,  702. 
Prostatitis,  699. 
Pruritus  ani,  653. 
Psammoma,  88. 
Pseudarthrosis,  175. 
Pseudoglioma,  495. 
Psoas  abscess,  586. 
Pterygium,  489. 
Ptosis,  486. 

Pubes,  dislocation  on,  434. 
Pudenda,  injuries  of,  400. 
Pulleys  in  dislocation,    190,  410,  438, 

440. 
Pulpy  degeration  of  joints,  243. 
Pulsatile  tumors  of  bone,  236,  277. 
Punctured  fracture  of  skull,  331. 

wound,   116. 
Puncture  of  bladder,  727. 
Purulent  catarrh  of  ear,  474. 
Pus,  characters  of,  37. 

formation  of,  36. 

varieties  of,  37. 
Pustule,  malignant,  150. 
Putrefaction,  prevention  of,  in  wounds, 

"3- 

Pyaemia,  155. 
Pyelitis,  667. 
I'yiilo-nephritis,  667. 
Pylorectomy,  616. 
Pyloroplasty,  619. 
Pyogenic  membrane,  223. 

zone,  36. 
Pyo-nephrosis,  669. 
-salpinx,  757. 


INDEX. 


OUIET  iritis,  493. 
necrosis,  222, 
"^    Quinsy,  531. 

RABIES,  160. 
Radial  artery,  ligature  of,  297. 
Radical  cure  of  hernia,  623. 

of  varicocele,  738. 
Radius,  dislocation  of,  414,  415. 

fracture  of,  425,  426. 

and  ulna,  fracture  of,  425. 
Railway  spine,  36S. 
Ranula,  517. 
Rarefying  osteitis,  216. 
Ray  fungus,  153. 
Raynaud's  disease,  58. 
Reaction  after  shock,  137. 

of  degeneration,  206, 
Rectocele,  401,  753. 
Recto-vaginal  fistula,  752. 
Rectum,  cancer  of,  664. 

diseases  of,  652. 

excision  of,  666. 

fissure  of,  654. 

foreign  bodies  in,  399. 

injuries  of,  399. 

malformations  of,  652. 

malignant  stricture  of,  664. 

polypus  of,  663. 

prolapse  of,  655. 

stricture  ot,  663. 

syphilis  of,  664. 

ulcer  of,  654. 

villous  tumor  of,  663. 
Recurrent  hsemorrhage,  133. 
Reduction  "  en  masse,"  639. 

in  dislocation,  188. 

of  shoulder,  409. 
Reduction  of  compound  dislocation  of 

shoulder  by  open  incision,  412. 

of  hip,  435. 

by  open  incision,  439. 
Reef-knot,  132. 
Reeves'  operation,  774. 
Refraction,  errors  of,  505. 
Renal  calculus,  670. 

colic,  671. 
Renal  hsematuria,  671. 
Repair,  process  of,   in  fractures,  170. 

in  wounds,  104. 
Resection  of  joints,  256. 

lower  jaw,  540. 
upper  jaw,  539. 
Residual  abscess,  41. 
Retained  testis,  748. 

34* 


Retention  of  urine,  723. 
Retina,  detachment  of,  501. 

diseases  of,  501. 
Retinitis,  501. 
Retinoscopy,  483. 
Retro-bulbar  neuritis,  500. 

pharyngeal  abscess,  554. 
Rhagades,  69. 
Rheumatoid  arthritis,  249. 
Rhinitis,  543. 
Rbinoliths,  547. 
Rhinoscopy,  543. 
Ribs,  fracture  of,  368. 
Richter's  hernia,  63c. 
Rickets,  226. 
Rider's  bone,  261. 
Risus  sardonicus,  166. 
Rodent  ulcer,  514. 
Rolando,  line  of,  344. 
Rouge's  operation,  549. 
Roughton's  splint,  459. 
Rupia,  68. 
Rupture  of  abdominal  viscera,  377. 

of  aneurysm,  274,  276. 

of  artery,  196. 

in  fracture,  185. 

of  bladder,  396. 

of  muscle,  195,  403,  429. 

of  oesophagus,  357. 

of  perineum,  400. 

of  tendon,  196,  403,  429. 

of  urethra,  398. 

SACRO-ILIAC  jomt,  disease  of,  24 
Sacculated  aneurysm,  273. 
Sacculated  bladder,  701,  708. 
Saline  solution,  infusion  of,  125. 
Salivary  calculus,  517. 

fistula,  350. 
Salpingitis.  757. 
Sankey's  force j)s,  571. 
Sapraemia,  143. 
Saprophytic  bacteria,  24. 
Sarcoma,  86. 

alveolar,  88. 

of  bone,  233. 

of  breast,  764. 

giant-celled,  90. 

glio-,  88. 

lympho-,  88. 

melanotic,  88. 

mixed-celled,  91. 

myeloid,  90. 

osteo-,  233. 

round-celled,  87 


8io 


INDEX. 


Sarcoma,  spindle-celled,  89. 
Sayre's  jacket,  589. 

method    of   treating    fractured 
clavicle,  418,  419. 
Scab,  healing  under,  106,  109. 
Scalds,  120. 
Scalp,  abscess  of,  462. 

cellulitis  of,  462. 

contusion  of,  327. 

diseases  of,  462. 

erysipelas  of,  462. 

hsematoma  of,  327. 

injuries  of,  327. 

sebaceous  cysts  of  462. 

tumors  of  464. 

wounds  of,  328. 
Scapula,  fractures  of,  419,  420. 
Schrapnell's  membrane,  469. 
Schroeder"s  operation,  758. 
Sciatic    notch,    dislocation  into,    431, 

432. 
Sciatica,  315. 
Scirrhous  carcinoma,  93, 

of  breast,  767. 
Scleritis,  492. 

Sclero- corneal  wounds,  492. 
Sclerotic,  disease  of,  490. 

wounds  of,  492. 
Scoliosis,  580. 
Scorbutic  ulcers,  51, 
Scotoma,  485. 
Scrofula  {see  Struma). 
Scrotum,  diseases  of,  732. 

epithelioma  of,  732. 

elephantiasis  of,  733. 
Scrotum,  erysipelas  of,  733. 

injuries  of,  402. 

oedema  of,  733. 
Scurvy  rickets,  228. 
Sebaceous  cysts,  99. 

deep,  of  neck,  517. 

on  scalp,  462. 
Second  intention,  healing  Ijy,  105,  108. 
Secondary  hecmorrhage,  133. 
Semilunar    cartilages,    dislocation    of, 

441. 
Senile  gangrene,  56. 
Senn's  method  of  gastro-enterostomy, 
617,618. 

method  of  uniting  divided  in- 
testine, 383. 

bone-ferrules  for  mixing  frag- 
ments, 178. 

bone-plates.  388,  389. 
Separation  of  epiphyses,  180,  424,  427. 


Septic  fever,  138. 

infection,  154. 

intoxication,  143. 

processes   in  wounds,   diseases 
due  to,  141,  142. 

traumatic  fever,  142. 
Septiccemia,  154. 
Septum  nasi,  deflection  of,  550. 

diseases  of,  550. 

injuries  of,  350. 

malformation  of,  550. 
Sequestrotomy,  222. 
Sero-cystic  disease  of  breast,  765. 
Serous  cysts,  100,  766. 
Serpents,  bites  of,  iiS. 
Shock,  136. 
Shoulder,  amputation  at,  787. 

compound  dislocation,  412. 

dislocation  of,  406. 

excision  of,  257. 
Sinus,  43. 

Skey's  tourniquet,  280. 
Skin  grafting,  47. 
Skin,  surgical  diseases  of,  320. 
Skull,  caries  of,  462. 

contusions  of,  329. 

diseases  of,  462. 

fracture  of,  329. 

of  base  of,  333. 

injuries  of,  329. 

necrosis  of,  462. 
Skull,  trephining  the,  347. 

tumors  of,  463,  464. 
Sloughing  phagedena,  49,  149. 

ulcer,  48. 
Smith's,  Stephen,  amputation,  789. 

gag>  528. 

needles,  528,  529. 
Snake-bites,  118. 
Snellen's  test-types,  484. 
Snuffles,  74. 

Sounding  fcir  stone,  686. 
Spasm  of  the  osso])hagus,  556. 

of  the  urethra,  706. 
Spasmodic  stricture,  706. 
Specula,  aural,  468. 
Spernialic  cord,  diseases  of,  737. 
Iiydroccle  of,  737. 
torsion  of,  739. 
tumors  of,  739. 
varicocele  of,  737. 
Sphacelus,  52. 

Sphenoidal  sinus,  catarrh  of,  553. 
S[)ica  bandage,  623. 
Spina  bilida,  591. 


INDEX. 


8ll 


Spinal  cord,  injuries  of,  363. 
Spine,  caries  of,  584. 

concussion  of,  368. 

curvature,  angular,  of,  584. 
lateral,  of,  580. 

diseases  of,  580. 

dislocation  of,  363. 

extension  of,  367. 

fracture-dislocation  of,  364. 

fractures  of,  363. 

injuries  of,  362. 

Pott's  disease  of,  584. 

railway,  368. 

sprains  of,  362. 

trephining,  367. 

wounds  of,  363. 
Spleen,  extirpation  of,  619. 

rupture  of,  378. 

wound  of,  381. 
Splenectomy,  619. 
Splint,  box,  460. 

Bryant's,  450. 

Cline's,  458. 

Dupuytren's,  459. 

Liston's,  449. 

Manning's,  454. 

Roughton's,  459. 
Splints,  174. 

Bavarian,  174. 
Spongy  gums,  533. 
Spontaneous  aneurysm,  270. 
Sprains,  186,  403,  429. 
Spreading  traumatic  gangrene,  56. 
Squint,  507. 
Staphyloma,  491,  506. 
Staphylorrhaphy,  528. 
Staphylococcus  pyogenes  aureus,  38. 
Stasis  in  inflammation,  19. 
Sterno-mastoid  muscle,  contraction  of, 
772. 

division  of,  773. 
Sternum,  dislocation  of,  369. 

fracture  of,  369. 
Stiff-joint,  254. 
Stings  of  insects,  118. 
Stomach,  rupture  of,  378. 

dilatation  of   the   cardiac  and 
pyloric  ends  of,  618. 

opening  the,  559. 

wound  of,  381. 
Stomatitis,  515. 
Stone,  (5d'<?  Calculus). 
Stop-needle,  499. 
Strabismus,  507. 
Strangulated  hernia,  629. 


Strangulation,  internal,  595,  601,  604. 
Streptococcus  erysipelatosus,  145. 

pyogenes,  38. 
Stricture  of  oesophagus,  556,  557. 

of  intestines,  595,  597,  601,  604. 

of  pharynx,  554. 

of  rectum,  663. 

of  urethra,  706. 
Stromeyer's  cushion,  424. 
Struma,  63. 

causes  of,  64. 

symptoms  of,  64. 
Strumous  glands,  312. 

testicle,  743. 

ulcer,  50. 
Stye,  486. 

Styptics  in  haemorrhage,  130. 
Subastragaloid  dislocation,  443. 
Subclavian  aneurysm,  287. 

artery,  ligature  of,  295. 
Subclavicular  dislocation,  40S. 
Subcoracoid  dislocation,  407. 
Subcutaneous  wounds,  119. 
Subglenoid  dislocation,  408. 
Subhyoid  pharyngotomy,  566, 574, 575. 
Sublingual  cysts,  517. 
Subluxation  of  jaw,  353. 
Subspinous  dislocation,  408. 
Superior   thyroid   artery,  ligature    of, 

295- 
Suppression  of  urine,  672. 
Suppuration,  34. 

diffuse,  42. 

effects  of,  42. 

in  bone,  223. 
Suprapubic  lithotomy,  696. 
Suture-catcher,  529. 
Sutures,  in. 

continuous,  1 12. 

interrupted,  1 1 2. 

Lembert's,  378,  382. 

Maunsell's,  384,  3S6. 

Paul's,  386. 

Senn's,  383. 
Symblepharon,  486. 
Syme's  amputation,  789. 

operation  for  aneurysm,  289. 
for  stricture,  716. 

staff,  716. 
Symonds'  tubes,  558. 
Sympathetic  inflammation  of  eye,  495. 

irritation,  495. 
Syndesmotomy,  781. 
Synechia,  491,  492. 
Synovitis,  acute,  236. 


8X2 


INDEX. 


Synovitis,  chronic,  237. 

strumous,  243. 
Syphilides,  68. 
Syphilis,  65. 

bone  disease  in,  74,  225. 

congenital,  73. 

primar)-,  66. 

secondary-,  68. 

tertiary,  70. 

in  tongue,  521,  524. 

treatment  of,  71. 
Syphilitic  gummata,  70. 

iritis,  69. 

teeth,  75. 

ulcers,  50. 
Syringo-myelocele,  592. 

nPALIPES,  775. 
J^  calcaneus,  778,  7S3. 

cavus,  779. 

equinus,  776,  783. 

valgus,  778,  784. 

varus,  777,  783. 
Tapping  abdomen,  614, 

hydrocele,  735. 

pericardium,  375. 

pleura,  374. 
Tarsectomy,  781. 

Tarsometatarsal  amputation,  791. 
Tarsotomy,  781. 
Tarsus,  dislocation  of,  444. 

fracture  of,  460. 
Taxis,  632. 

Teale's  amputation.  786. 
Teeth,  mercurial,  75. 

syphilitic,  75. 
Temporal  artery,  ligature  of,  295. 
Tendons,  injuries  of,  194. 

diseases  (jf,  261. 

dislocation  of,  195. 

division  of,  780. 

evulsion  of,  196. 

rupture  of,  196,  403,  429. 

wounds  of,  195. 
Teno-synovitis,  261. 
Tenotomy,  780. 

of  recti,  508. 

of  tibials,  781. 

of  tendo  Achillis,  783. 
Testis,  atrophy  of,  748. 

diseases  of,  741. 

enchondroma  of,  746. 

encysted  hydrocele  of,  736. 

excision  of,  748. 

inflanmiation  of,  741,  742. 


Testis,  injuries  of,  402. 

malignant  disease  of,  746. 

neuralgia  of,  748. 

retained,  748. 

syphilis  of,  744. 

tubercle  of,  743. 
Tetanus,  164. 

anti-toxin,  167. 
Thiersch's  method  of  skin-grafting,  47. 
1  Thigh,  amputation  of,  789. 
!  Thomas'  splint  for  knee,  239. 
for  hip,  238. 
for  spinal  caries,  588. 
1  Thoracoplasty,  375. 
I  Thorax,  injuries  of  (^see  Chest). 
Thrombosis,  302. 
Thrush,  516. 
Thumb,  amputation  of,  788. 

dislocation  of,  416. 
Thyroid  body,  diseases  of,  577. 

foramen,  dislocation  into,  434. 

gland,  diseases  of,  577. 
Thyrotomy,  566,  574. 
Tibia,  fracture  of,  455. 
Tibial  arteries,  ligature  of,  301. 
Tic,  convulsive,  319. 
Tinea  tarsi,  485. 
Tinnitus  aurium,  481. 
Toe-nail,  hypertrophy  of,  326. 

ingrowing,  326. 
Toes,  amputation  of,  791. 
Tongue,  diseases  of,  518. 

abscess  of,  519. 

epithelioma  of,  522. 

excision  of,  524. 

gumma  of,  522,  524. 

hypertrophy  of,  519. 

inflammation  of,  519. 

non-differentiation  of,  518. 

syphilis  of,  521,  524. 

tumors  of,  523. 

ulcers  of,  520. 
Tongue-tie,  518. 
Tonsil,  diseases  of,  527,  532. 

excision  of,  532. 

hypertrophy  of,  531. 
Tonsillitis,  530. 
Torsion  of  arteries,  132. 
Torticollis,  772. 
Tournicjucts,  129,  280. 
Toxic  am])lyopia,  500. 
Toynbee's  drum,  475. 
Trachea,  foreign  jjodies  in,  354. 

subcutaneous  rupture  of,  356. 

wounds  of,  354. 


INDEX. 


813 


Tracheotomy,  564,  566,  568,  573. 
Trachoma,  489. 
Traction,  reduction  by,  436. 
Transfusion  of  blood,  125. 
Transplantation    of    tubercle    of    the 

tibia,  441. 
Traumatic  aneurysm,  201. 

delirium,  139. 

fever,  138,  142. 

gangrene,  55. 

peritonitis,  393. 
Trephining  bone,  224. 

skull,  347,  466. 

spine,  367. 
Trichiasis,  486. 
Trismus,  166. 
Trusses,  623,  629. 
Tubercle,  58. 

bacillus,  60. 

causes  of,  61. 

development  of,  60. 

dissemination  of,  61. 

in  bone,  225. 

localization  of,  62. 

of  the  tibia,  transplantation  of, 
441. 

secondary  changes  in,  60. 

structure  of,  59. 

treatment  of,  63. 
Tubercles,  mucous,  63. 
Tuberculous  ulcers,  50. 
Tuberculosis,  58. 
Tufnell's,  Joliffe,diet  scale  in  aneurysm, 

278. 
Tumor  albus,  244. 
Tumors,  77. 

of  bladder,  683. 

of  bone,  230. 

of  brain,  464. 

causes  of,  78. 

classification  of,  80. 

development  of,  77. 

dissemination  of,  80. 

innocent,  79. 

of  kidney,  672. 

malignant,  79. 

of  nerves,  318. 

secondary  changes  in,  79. 

of  tongue,  523. 

varieties  of,  80. 
Turbinal  erection,  546. 
Typhlectomy,  611. 
Typhlitis,  597,  602,  605. 


ULCERATION,  44. 
causes  of,  45. 
minute  changes  in,  19. 
treatment  of,  45. 
Ulcers,  46. 

anal,  654. 
callous,  49. 
chronic,  49. 
dental,  520. 
dyspeptic,  520. 
eczematous,  49. 
exuberant,  47. 
fungous,  47. 
gouty,  51. 
healing,  46. 
inflamed,  48. 
inflammatory,  48. 
irritable,  50. 
cedematous,  47. 
perforating,  319. 
phagedtenic,  48. 
rodent,  514. 
scorbutic,  51. 
simple,  46. 
sloughing,  48. 
strumous,  50. 
syphilitic,  50. 
tuberculous,  50. 
varicose,  49,  306. 
varieties  of,  46. 
Ulna,  dislocation  of,  414,415. 

fracture  of,  425,  427. 
Ulnar  artery,  ligature  of,  296. 
Umbilical,  649. 
Ungual  exostosis,  231. 
Union  of  wounds,  104. 

of  intestines  by  Senn's  plates, 
388. 
j  Unreduced  dislocations,  189. 
I  Ununited  fracture,  175. 
'  Upper  extremity,  dislocation  of,  403. 
j  fraaures  of,  417. 

injuries  of,  403. 
j  Uranoplasty,  529. 
Urates,  674. 
Ureter,  dilatation  of,  708. 

rupture  of,  378. 
Urethra,  calculus  in,  722. 
dilatation  of,  711. 
diseases  of,  703. 
foreign  body  in,  400,  402. 
inflammation  of,  703. 
injury  of,  398. 
rupture  of,  398. 
stricture  of,  706. 


8i4 


INDEX. 


Urethra,  tumors  of,  723. 
Urethral  Hthotomy,  697. 
Urethritis,  703. 
Urethrometer,   709. 
Urethrotome,  715,  716. 
Urethrotomy,  external,  716. 

internal,  713. 
Uric  acid  calculi,  677. 

deposits,  674. 
Urinary  abscess,  719. 

calculus,  677. 

deposits,  674. 

fistula,  720. 

organs,  diseases  of,  667. 
Urine,  blood  in,  698. 

extravasation  of,  721. 

incontinence  of,  697. 

retention  of,  723. 

suppression  of,  672. 
Utero-rectal  fistula,  752. 

-vesical  fistula,  752. 
Uterus,  extirpation  of,  758. 
Uveal  tract,  disease  of,  492. 
Uveitis,  494. 

Uvula,  elongation  of,  527. 
Uvulitis,  527. 

\7'AGINA,  cysts  of,  751. 
diseases  of,  751. 

fistula  of,  751. 

foreign  bodies  in,  400. 

injuries  of,  400. 

malformations  of,  752. 

tumors  of,  751. 

wounds  of,  400. 
Vaginal  lithotomy,  697. 
Vaginitis,  751. 
Varicocele,  737. 
Varicose  aneurysm,  202. 

ulcer,  49,  307. 

veins,  306,  307. 
Varix,  aneurysmal,  202. 
Vascular  tumor  of  urethra,  723. 
Vault  of  skull,  fracture  of,  329. 
Veins,  diseases  of,  302. 

entrance  of  air  in,  204. 

injuries  of,  203. 

ru])ture  of,  203. 

varicose,  306,  307. 

wounds  of,  203. 
Venereal  diseases,  65,  730, 

sore,  730. 
Ventral  hernia,  652. 
Ventricles,  tajjping,  in  hyrlrocephalus, 

467. 


Verrucoe,  320. 
Vesico-intestinal  fistula,  683. 

-vaginal  fistula,  751. 
Vesicocele,  401. 
Vicious  union,  179. 
Villous  growths,  85. 

of  bladder,  684. 

of  larynx,  566. 

of  rectum,  663. 

tumors,  84. 
Viscera,  abdominal,  injury  of,  3S0. 

protrusion  of,  392. 

rupture  of,  377. 
Vitreous,  diseases  of,  502. 
Volvulus,  595,  601,  604. 
Vulva,  diseases  of,  749. 

injuries  of,  400. 

pruritus  of,  750. 
Vulvitis,  749. 

WALLERIAN  degeneration,  205 
Wardrop's  operation  for  aneu- 
rysm, 282,  286. 
Warts,  320. 

venereal,  320. 
Warty  tumors,  84. 
Wax  in  ear,  472. 
Wens,  81,  99. 
Wheelhouse's  operation,  718. 

staff,  718. 
White  swelling,  244. 
Whitehead's  operation  for  removal  of 

tongue,  525. 
Whitlow,  263. 
Wille's  method  of  wiring  fragments, 

178. 
Wire-twister,  529. 
Wiring  the  patella,  455. 

fragments  in  fracture,  178. 
Wound-diphtheria,  150, 
Wounds,  closure  of,  iii. 

cleansing  of,  no. 

constitutional  treatment  of,  114. 

contused,  n6. 

dissection,  117. 

drainage  of,  1 10. 

healing  of,  104. 

incised,  115. 

lacerated,  116. 

open,  104. 

poisoned,  117. 

prevention  of  putrefaction   in, 

"3- 
punctured,  116. 
repair  of,  104. 


INDEX. 


815 


Wounds,  subcutaneous,  119. 

treatment  of,  109. 

varieties  of,  115. 
Wrist,  amputation  at,  787. 

dislocation  of,  415. 

excision  of,  258. 


Wryneck,  772. 

Y  LIGAMENT,  430. 
Yearsley's  drum,  475. 

'yOOGLCEA  masses,  24. 


Catalogue  No.  8.  May.  1898. 

CLASSIFIED  SUBJECT 
CATALOGUE 

OF 

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SUBJECT   INDEX. 


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SUBJECT.  PAGE 

Alimentary  Canal  (see  Surgery)  19 

Anatomy 3 

Anesthetics 3 

Autopsies  (see  Pathology) 16 

Bandaging  (see  Surgery) 19 

Brain  4 

Chemistry 4 

Children,  Diseases  of 6 

Clinical  Charts 6 

Compends 22,  23 

Consumption  (see  Lungs) 12 

Deformities 7 

Dentistry 7 

Diagnosis 17 

Diagrams  (see  Anatomy,  page 
3,  and  Oijstetrics,  page  16). 

Dictionaries 8 

Diet  and  Food  (see  Miscella- 
neous)    14 

Dissectors 3 

Domestic  Medicine 10 

Ear 8 

Electricity 9 

Emergencies  (see  Surgery) 19 

Eye 9 

Fevers 9 

Gout  10 

Gynecology 21 

Hay  Fever 20 

Headaches 10 

Heart lo 

Histology 10 

Hospitals  (see  Hygiene) 11 

Hygiene 11 

Insanity  4 

Latin,   Medical  (see  Miscella- 
neous and  Pharmacy) 14,  16 

Lungs 12 

Massage 12 

Materia  Medica 12 

Medical  Jurisprudence 13 

Microscopy  13 

Milk  Analysis  (see  Chemistry)  4 

Miscellaneous  14 


SUBJECT.  PAGE 

Nervous  Diseases  14 

Nose 20 

Nursing 15 

Obstetrics 16 

Ophthalmology 9 

Osteology  (see  Anatomy) 3 

Pathology 16 

Pharmacy 16 

Physical  Diagnosis 17 

Physical  Training  (see  Miscel- 
laneous)    14 

Physiology  18 

Poisons  (see  Toxicology) 13 

Popular  Medicine 10 

Practice  of  Medicine 18 

Prescription-  Books 18 

Railroad  Injuries  (see  Nervous 

Diseases) 14 

Refraction  (see  Eye) 9 

Rheumatism  10 

Sanitary  Science 11 

Skin 19 

Spectacles  (see  Eye) 9 

Spine  (see  Nervous  Diseases)  14 
Stomach  (see  Miscellaneous)...  14 

Students'  Compends 22,  23 

Surgery  and  Surg.  Diseases...  19 

Syphilis 21 

Technological  Books 4 

Temperature  Charts 6 

Therapeutics 12 

Throat  20 

Toxicology 13 

Tumors  (see  Surgery) 19 

U.  S.  Pharmacopoeia 16 

Urinary  Organs 20 

Urine 30 

Venereal  Diseases 21 

Veterinary  Medicine 21 

Visiting  Lists,  Physicians'. 

{Send /or  Special  Circular.) 
Water  Analysis  (see  Chemis- 
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Women,  Diseases  of. 21 


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CALDWELL.  Elements  of  Qualitative  and  Quantitative 
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CLOWES  AND  COLEMAN.  Elementary  Practical  Chem- 
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GARDNER.  The  Brewer,  Distiller,  and  'Wine  Manufac- 
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GARDNER.  Bleaching,  Dyeing,  and  Calico  Printing.  With 
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GROVES  AND  THORP.  Chemical  Technology.  The  Appli- 
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with  numerous  Illustrations. 

Vol.  I.  Fuel  and  Its  Applications.     607  Illustrations  and  4  Plates. 

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HOLLAND.  The  Urine,  the  Gastric  Contents,  the  Common 
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LEFFMANN.  Compend  of  Medical  Chemistry,  Inorganic 
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LEFFMANN.  Progressive  Exercises  in  Practical  Chemis- 
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LEFFMANN.    Water  Analysis.     Illustrated.    3d  Edition.    Jx.25 

LEFFMANN.  Structural  Formulae.  Including  180  Structural 
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MUTER.  Practical  and  Analytical  Chemistry.  4th  Edition. 
Revised  to  meet  the  requirements  of  American  Medical  Colleges  by 
Claude  C.  Hamilton,  m.d.     51  Illustrations.  ^1.25 

OETTEL.  Practical  Exercises  in  Electro-Chemistry.  Illus- 
trated. .75 

OETTEL.     Introduction  to    Electro-Chemical    Experiments. 

Illustrated.  .75 

RICHTER.  Inorganic  Chemistry.  4th  American,  from  6th  Ger- 
man Edition.  Authorized  translation  by  Edgar  F.  Smith,  m.a., 
PH.D.     89  Illustrations  and  a  Colored  Plate.  ^1-75 

RICHTER.  Organic  Chemistry.  3d  American  Edition.  Trans, 
from  the  last  German  by  Edgar  F.  Smith.     Illustrated.    In  Press. 

SMITH.    Electro-Chemical  Analysis.    2d  Edition,  Revised.    28 

Illustrations.  |i-2S 

SMITH  AND  KELLER.     Experiments.    Arranged  for  Students 

in  General  Chemistry.     3d  Edition.     Illustrated.  .60 

STAMMER.     Chemical  Problems.     With  Answers.  ,50 


SUBJECT  CATALOGUE. 


SUTTON.  Volumetric  Analysis.  A  Systematic  Handbook  for 
the  Quantitative  Estimation  of  Chemical  Substances  by  Measure, 
Applied  to  Liquids,  Solids,  and  Gases.  7th  Edition,  Revised.  112 
Illustrations.  ^4.50 

SYMONDS.  Manual  of  Chemistry,  for  Medical  Students. 
2d  Edition.  J2.00 

WOODY.  Essentials  of  Chemistry  and  Urinalysis.  4th 
Edition.     Illustrated.  In  Press. 

***  Special  Catalogue  of  Books  on  Chemistry  free  ufon  application. 

CHILDREN. 

CAUTLIE.  Feeding  of  Infants  and  Young  Children  by  Nat- 
ural and  Artificial  Methods,     fust  Ready.  J2.00 

HALE.  On  the  Management  of  Children  in  Health  and  Dis- 
ease. .50 

HATFIELD.  Compend  of  Diseases  of  Children.  With  a 
Colored  Plate.     2d  Edition.  .80;    Interleaved,  |i. 25 

IRELAND.  Mental  Affections  of  Children.  Idiocy,  Imbe- 
cility, etc.  In  Press. 

MEIGS.  Infant  Feeding  and  Milk  Analysis.  The  Examination 
of  Human  and  Cow's  Milk,  Cream,  Condensed  Milk,  etc.,  and 
Directions  as  to  the  Diet  of  Young  Infants.  .50 

MONEY.  Treatment  of  Diseases  in  Children.  Including  the 
Outlines  of  Diagnosis  and  the  Chief  Pathological  Differences  Between 
Children  and  Adults,     ad  Edition.  $2.50 

PO'WER.  Surgical  Diseases  of  Children  and  their  Treat- 
ment by  Modern  Methods.     Illustrated.  $^-So 

STARR.  The  Digestive  Organs  in  Childhood.  The  Diseases  of 
the  Digestive  Organs  in  Infancy  and  Childhood.  With  Chapters  on 
the  Investigation  of  Disease  and  the  Management  of  Children.  2d 
Edition,  Enlarged.  Illustrated  by  two  Colored  Plates  and  numerous 
Wood  Engravings.  ^2,00 

STARR.  Hygiene  of  the  Nursery.  Including  the  General  Regi- 
men and  Feeding  of  Infants  and  Children,  and  the  Domestic  Manage- 
ment of  the  Ordinary  Emergencies  of  Early  Life,  Massage,  etc.  6th 
Edition.     25  Illustrations.    Just  Ready.  fi.oo 

TAYLOR  AND  "WELLS.  The  Diseases  of  Children.  Illus- 
trated.    A  New  Text-Book.  Nearly  Ready. 

CLINICAL  CHARTS. 

GRIFFITH.  Graphic  Clinical  Chart  for  Recording  Temper- 
ature, Respiration,  Pulse,  Day  of  Disease,  Date,  Age,  Sex, 
Occupation,  Name,  etc.  Printed  in  three  colors.  Sample  copies 
free.  Put  up  in  loose  packages  of  fifty,  .50.  Price  to  Hospitals,  500 
copies,  J4.00;  1000  copies,  $7.50.  With  name  of  Hospital  printed 
on,  .50  extra. 

KEEN'S  CLINICAL  CHARTS.  Seven  Outline  Drawings  of  the 
Body,  on  which  may  be  marked  the  Course  of  Disease,  Fractures, 
Operations,  etc.  Pads  of  fifty,  Ji.co.  Each  Drawing  may  also  be 
had  separately,  twenty-five  to  pad,  25  cents. 

SCHREINER.  Diet  Lists.  Arranged  in  the  form  of  a  chart. 
Pads  of  50.  .75 


MEDICAL  BOOKS. 


DEFORMITIES. 

REEVES.  Bodily  Deformities  and  Their  Treatment.  A 
Hand-Book  of  Practical  Orthopedics.     228  Illustrations.  Ji-TS 

HEATH.  Injuries  and  Diseases  of  the  Jaws.  187  Illustrations. 
4th  Edition.  Cloth,  $4.50 

DENTISTRY. 

special  Catalogite  0/  Dental  Books  sent  free  upon  application. 

BARRETT.  Dental  Surgery  for  General  Practitioners  and 
Students  of  Medicine  and  Dentistry.  Extraction  of  Teeth, 
etc.     3d  Edition.     Illustrated.  Nearly  Ready. 

BLODGETT.  Dental  Pathology.  By  Albert  N.  Blodgktt, 
M.D.,  late  Professor  of  Pathology  and  Therapeutics,  Boston  Dental 
College.     33  Illustrations.  ?i-2S 

FLAGG.  Plastics  and  Plastic  Filling,  as  Pertaining  to  the  Filling 
of  Cavities  in  Teeth  of  all  Grades  of  Structure.     4th  Edition.       J4.00 

FILLEBROWN.  A  Text-Book  of  Operative  Dentistry. 
Written  by  invitation  of  the  National  Association  of  Dental  Facul- 
ties.    Illustrated.  $2.25 

QORGAS.  Dental  Medicine.  A  Manual  of  Materia  Medica  and 
Therapeutics.     6th  Edition,  Revised.  Cloth,  J4.00;  Sheep,  J5.00 

HARRIS.  Principles  and  Practice  of  Dentistry.  Including 
Anatomy,  Physiology,  Pathology,  Therapeutics,  Dental  Surgery, 
and  Mechanism.  13th  Edition.  Revised  by  F.  J.  S.  Gorgas,  m.d., 
D.D.s.     1250  Illustrations.  Cloth,  J6.00;  Leather,  $7.00 

HARRIS.  Dictionary  of  Dentistry.  Including  Definitions  of  Such 
Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain  to  the  Art  and 
Practice  of  Dentistry.  5th  Edition.  Revised  and  Enlarged  by  Fer- 
dinand F.  S.  Gorgas,  m.d.,  d.d.s.  Cloth,  J4.50  ;  Leather,  $5.50 

HEATH.  Injuries  and  Diseases  of  the  Jaws.  4th  Edition.  187 
Illustrations.  J4.50 

HEATH.  Lectures  on  Certain  Diseases  of  the  Jaws.  64 
Illustrations.  Boards,  .50 

RICHARDSON.  Mechanical  Dentistry.  7th  Edition.  Thor- 
oughly Revised  and  Enlarged  by  Dr.  Geo.  W.  Warren.  691  Illus- 
trations. Cloth,  ^5.00;  Leather,  ^6.00 

SEWELL.  Dental  Surgery.  Including  Special  Anatomy  and 
Surgery.     3d  Edition,  with  200  Illustrations.  $2.00 

TAFT.  Operative  Dentistry.  A  Practical  Treatise.  5th  Edition. 
100  Illustrations.  In  Press. 

TAFT.     Index  of  Dental  Periodical  Literature.  fi.oo 

TALBOT.  Irregularities  of  the  Teeth  and  Their  Treatment. 
2d  Edition.     234  Illustrations.  $300 

TOMES.     Dental  Anatomy.    Human  and  Comparative.    263  Illus- 
trations.    5th  Edition.    Just  Ready.  ^4.co 
TOMES.     Dental  Surgery.  3d  Edition.     292  Illustrations.        ^4.00 
WARREN.     Compend  of  Dental  Pathology  and  Dental  Medi- 
cine.    With  a  Chapter  on  Emergencies.     3d  Edition.     Illustrated. 
Jxtst  Ready.                                                              .80;  Interleaved,  $1.25 
WARREN.  Dental  Prosthesis  and  Metallurgy.  129  Ills.  J1.25 
WHITE.     The  Mouth  and  Teeth.     Illustrated.  .40 
%*  Special  Catalogue  of  Dental  Books  free  upon  application. 


SUBJECT  CATALOGUE. 


DICTIONARIES. 

GOULD.  The  Illustrated  Dictionary  of  Medicine,  Biology, 
and  Allied  Sciences.  'Being  an  Exhaustive  Lexicon  oi  Medicine 
and  those  Sciences  Collateral  to  it:  Biology  (Zoology  and  Botany), 
Chemistry,  Dentistry,  Parmacology,  Microscopy,  etc.,  with  many 
usefiil  Tables  and  numerous  fine  Illustrations.  1633  pages.  3d  Ed. 
Sheep  or  Half  Dark  Green  Leather,  ;fio.oo;  Thumb  Index,  Jii.oo 
Half  Russia,  Thumb  Index,  J12. 00 

GOULD.  The  Medical  Student's  Dictionary.  Including  all  the 
Words  and  Phrases  Generally  Used  in  Medicine,  with  their  Proper 
Pronunciation  and  Definition,  Based  on  Recent  Medical  Literature. 
With  Tables  of  the  Bacilli,  Micrococci,  Mineral  Springs,  etc.,  of  the 
Arteries,  Muscles,  Nerves,  Ganglia,  and  Plexuses,  etc.  loth  Edition. 
Rewritten  and  Enlarged.  Completely  reset  from  new  type.  700  pp. 
Half  Dark  Leather,  $3.25 ;  Half  Morocco,  Thumb  Index,  $4.00 

GOULD.  The  Pocket  Pronouncing  Medical  Lexicon.  (12,000 
Medical  Words  Pronounced  and  Defined.)  Containing  all  the  Words, 
their  Definition  and  Pronunciation,  that  the  Medical,  Dental,  or 
Pharmaceutical  Student  Generally  Comes  in  Contact  With ;  also 
Elaborate  Tables  of  the  Arteries,  Muscles,  Nerves,  Bacilli,  etc.,  etc., 
a  Dose  List  in  both  English  and  Metric  System,  etc..  Arranged  in  a 
Most  Convenient  form  for  Reference  and  Memorizing. 

Full  Limp  Leather,  Gilt  Edges,  Ji.oo  ;  Thumb  Index,  J1.25 
70,000  Copies  of  Gould's  Dictionaries  Have  Been  Sold. 
*^*  Sample  Pages   and    Illustrations  and    Descriptive   Circulars    of 

Gould's  Dictionaries  sent  free  upon  application. 

HARRIS.  Dictionary  of  Dentistry.  Including  Definitions  of  Such 
Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain  to  the  Art 
and  Practice  of  Dentistry.  5th  Edition.  Revised  and  Enlarged  by 
Ferdinand  J.  S.  Gorcas,  m.d.,  d.d.s.   Cloth,  I4.50;  Leather,  J5.50 

LONGLEY.  Pocket  Medical  Dictionary.  With  an  Appendix, 
containing  Poisons  and  their  Antidotes,  Abbreviations  used  in  Pre- 
scriptions, etc.  Cloth,  .75  ;  Tucks  and  Pocket,  |i.oo 

MAXWELL.  Terminologia  Medica  Polyglotta.  By  Dr. 
Theodore  Maxwell,  Assisted  by  Others.  J3.00 

The  object  of  this  work  is  to  assist  the  medical  men  of  any  nationality 

in   reading   medical  literature   written   in  a  langiiage  not   their  own. 

Each  term  is  usually  given  in  seven  languages,  viz.  :  English,  French, 

German,  Italian,  Spanish,  Russian,  and  Latin. 

TREVES  AND  LANG.    German-English  Medical  Dictionary. 

Half  Russia,  ^3.25 

EAR  (see  also  Throat  and  Nose). 

HOVELL.  Diseases  of  the  Ear  and  Naso-Pharjrnx.  Includ- 
ing Anatomy  and  Physiology  of  the  Organ,  together  with  the  Treat- 
ment of  the  Affections  of  the  Nose  and  Pharynx  which  Conduce  to 
Aural  Disease.     122  Illustrations.  IS-oo 

BURNETT.     Hearing  and  How  to  Keep  It.     Illustrated.  .40 

DALBY.  Diseases  and  Injuries  of  the  Ear.  4th  Edition.  38 
Wood  Engravings  and  8  Colored  Plates.  $'^■5° 

PRITCHARD.  Diseases  of  the  Ear.  3d  Edition,  Enlarged. 
Many  llhistrations  and  Formulae.  j^i.SO 

WOAKES.  Deafness,  Giddiness,  and  Noises  in  the  Head. 
4th  Edition.    Illustrated.  Ja.oo 


MEDICAL  BOOKS. 


ELECTRICITY. 

BIGELOV^.      Plain  Talks  on   Medical   Electricity  and  Bat- 
teries.    With  a  Therapeutic   Index  and  a   Glossary.       43  Illustra- 
tions.    2d  Edition.  $1.00 
JONES.    Medical  Electricity.   2d  Edition.   112  Illustrations.    $2.50 
MASON.    Electricity ;  Its  Medical  and  Surgical  Uses.    Numer- 
ous Illustrations.  .75 

EYE. 

A  Special  Circular  0/  Books  on  the  Eye  sent  free  upon  application. 

ARLT.  Diseases  of  the  Eye.  Clinical  Studies  on  Diseases  of  the 
Eye.     Translation  by  Lyman  Ware,  m.d.     Illustrated.  J'-zs 

DONDERS.  Aphorisms  upon  Refraction  and  Their  Results. 
8vo.  In  Press. 

PICK.  Diseases  of  the  Eye  and  Ophthalmoscopy.  Trans- 
lated by  A.  B.  Hale,  m.  d.  157  Illustrations,  many  of  which  are  in 
colors,  and  a  glossary.  Cloth,  54.50;  Sheep,  J5.50 

GOULD  AND  PYLE.  Compend  of  Diseases  of  the  Eye  and 
Refraction.  Including  Treatment  and  Operations,  and  a  Section 
on  Local  Therapeutics.  With  Formulae,  Useful  Tables,  a  Glossary, 
and  III  Illustrations,  several  of  which  are  in  colors.    Just  Ready. 

Cloth,  .80  ;  Interleaved,  ^1.25 

GOAVERS.  Medical  Ophthalmoscopy.  A  Manual  and  Atlas 
with  Colored  Autotype  and  Lithographic  Plates  and  Wood-cuts, 
Comprising  Original  Illustrations  of  the  Changes  of  the  Eye  in  Dis- 
eases of  the  Brain,  Kidney,  etc.     3d  Edition.  I4.00 

HARLAN.     Eyesight,  and  How  to  Care  for  It.     Illus.  .40 

HARTRIDGE.  Refraction.  96  Illustrations  and  Test  Types. 
8th  Edition,  Enlarged.  $1.50 

HARTRIDGE.  On  the  Ophthalmoscope.  3d  Edition.  With 
72  Colored  Plates  and  many  Wood-cuts.  Ji-5o 

HANSELL  AND  BELL.  Clinical  Ophthalmology.  Colored 
Plate  of  Normal  Fundus  and  120  Illustrations.  ^i-So 

MORTON.  Refraction  of  the  Eye.  Its  Diagnosis  and  the  Cor- 
rection of  its  Errors.  With  Chapter  on  Keratoscopy  and  Test 
Types.     6th  Edition.  Ji  00 

OHLEMANN.  Ocular  Therapeutics.  Authorized  Translation, 
and  Edited  by  Dr.  Charles  A.  Oliver.  In  Press. 

PHILLIPS.  Spectacles  and  Eyeglasses.  Their  Prescription 
and  Adjustment.     2d  Edition.     49  Illustrations.  $1.00 

SWANZY.  Diseases  of  the  Eye  and  Their  Treatment.  6th 
Edition,  Revised  and  Enlarged.  158  Illustrations,  i  Plain  Plate, 
and  a  Zephyr  Test  Card.  '  J3.00 

THORINGTON.    Retinoscopy,    ■zA'&A.  \\\n%.  Just  Ready.    Ji.oo 

WALKER.  Students'  Aid  in  Ophthalmology.  Colored  Plate 
and  40  other  Illustrations  and  Glossary.  ^i-5o 

FEVERS. 

COLLIE.  On  Fevers.  Their  History,  Etiology,  Diagnosis,  Prog- 
nosis, and  Treatment.     Colored  Plates.  J2.00 

GOODALL  AND  WASHBOURN.  Fevers  and  Their  Treat- 
ment.    Illustrated.  93-oo 


10  SUBJECT  CATALOGUE. 

GOUT  AND  RHEUMATISM. 

DUCK'WORTH.  A  Treatise  on  Gout.  With  Chromo-lithographs 
and  Engravings.  Cloth,  ^6.00 

GARROD.  On  Rheumatism.  A  Treatise  on  Rheumatism  and 
Rheumatic  Arthritis.  Cloth,  $5.00 

HAIG.  Causation  of  Disease  by  Uric  Acid.  A  Contribution  to 
the  Pathology  of  High  Arterial  Tension,  Headache,  Epilepsy,  Gout, 
Rheumatism,  Diabetes,  Bright's  Disease,  etc.    4th  Edition.       fe-oo 


HEADACHES. 

DAY.    On   Headaches.     The  Nature,  Causes,   and  Treatment  ot 
Headaches.     4th  Edition.     Illustrated.  Ji.oo 


HEALTH    AND     DOMESTIC    MEDI- 
CINE (see  also  Hygiene  and  Nursing). 

BUCKLEY.    The  Skin  in  Health  and  Disease.     lUus.  ,40 

BURNETT.     Hearing  and  How  to  Keep  It.     Illustrated.  .40 

COHEN.     The  Throat  and  Voice.     Illustrated.  .40 

DULLES.     Emergencies.    4th  Edition.     Illustrated.  Ji.oo 
HARLAN.     Eyesight  and  How  to  Care  for  It.     Illustrated.     .40 

HARTSHORNE.     Our  Homes.    Illustrated.  .40 

OSGOOD.    The  Winter  and  its  Dangers.  .40 

PACKARD.     Sea  Air  and  Bathing.  .40 

PARKES.     The  Elements  of  Health.  J1.35 

RICHARDSON.    Long  Life  and  How  to  Reach  It.  .40 

WESTLAND.     The  Wife  and  Mother.  $1.50 

WHITE.    The  Mouth  and  Teeth.     Illustrated.  .40 

■WILSON.     The  Summer  and  its  Diseases.  .40 

■WOOD.     Brain  Work  and  Overwork.  .40 

STARR.     Hygiene  of  the  Nursery.    5th  Edition.  ^i.oo 

CANFIELD.     Hygiene  of  the  Sick-Room.  J1.25 

HEART. 

SANSOM.  Diseases  of  the  Heart.  The  Diagnosis  and  Pathology 
of  Diseases  of  the  Heart  and  Thoracic  Aorta.  With  Plates  and  other 
Illustrations.  ^6.00 

HISTOLOGY. 

STIRLING.  Outlines  of  Practical  Histology.  368  Illustrations. 
2d  Edition,  Revised  and  Enlarged.     With  new  Illustrations.       ^2.00 

STOHR.  Histology  and  Microscopical  Anatomy.  Translated 
and  Edited  by  A.  bcHAPBR,  M.D.,  Harvard  Medical  School.  268 
Illustrations.        •  ^3-o° 


MEDICAL  BOOKS. 


HYGIENE  AND  WATER  ANALYSIS. 

special  Catalogue  of  Books  on  Hygiene  sent  free  upon  application. 

CANFIELD.  Hygiene  of  the  Sick-Room.  A  Book  for  Nurses 
and  Others.  Being  a  Brief  Consideration  of  Asepsis,  Antisepsis,  Dis- 
infection, Bacteriology,  Immunity,  Heating  and  Ventilation,  and 
Kindred  Subjects.  |i.2S 

COPLIN  AND  BEVAN.  Practical  Hygiene.  A  Complete 
American  Text-Book.     138  Illustrations.     Cloth,  J3. 25  ;  Sheep,  J4. 25 

FOX.  'Water,  Air,  and  Food.  Sanitary  Examinations  of  Water, 
Air,  and  Food.     100  Engravings.     2d  Edition,  Revised.  %'i-V^ 

KENWOOD.  Public  Health  Laboratory  Work.  116  Illustra- 
tions and  3  Plates.  J2.00 

LEFFMANN.  Examination  of  Water  for  Sanitary  and 
Technical  Purposes.    3d  Edition.   Illustrated.  Ji.zs 

LEFFMANN.  Analysis  of  Milk  and  Milk  Products.  Illus- 
trated. fi.zS 

LINCOLN.     School  and  Industrial  Hygiene.  .40 

MACDONALD.  Microscopical  Examinations  of  'Water  and 
Air.     25  Lithographic  Plates,  Reference  Tables,  etc.   2d  Ed.     $2.50 

McNEILL.  The  Prevention  of  Epidemics  and  the  Construc- 
tion and  Management  of  Isolation  Hospitals.  Numerous  Plans 
and  Illustrations.  fo-SO 

NOTTER  AND  FIRTH.  The  Theory  and  Practice  of  Hygiene. 
(Being  the  9th  Edition  of  Parkes'  Practical  Hygiene,  rewritten  and 
brought  up  to  date.)  10  Plates  and  135  other  Illustrations.  1034 
pages.     8vo.  J7.00 

PARKES.  Hygiene  and  Public  Health.  By  Louis  C.  Parkes, 
M.D.     5th  Edition.     Enlarged.     Illustrated.  552.50 

PARKES.  Popular  Hygiene.  The  Elements  of  Health.  A  Book 
for  Lay  Readers.     Illustrated.  Ji.*5 

STARR.  The  Hygiene  of  the  Nursery.  Including  the  General 
Regimen  and  Feeding  of  Infants  and  Children,  and  the  Domestic 
Management  of  the  Ordinary  Emergencies  of  Early  Life,  Massage, 
etc.     6th  Edition.     25  Illustrations.  Ji.oo 

STEVENSON  AND  MURPHY.  A  Treatise  on  Hygiene.  By 
Various  Authors.     In    Three    Octave   Volumes.     Illustrated. 

Vol.  I,  J6.00;  Vol.  II,  J6.oo;  Vol.  Ill,  I5.00 
*»*  Each  Volume  sold  separately.   Special  Circular  upon  application. 

■WILSON.  Hand-Bock  of  Hygiene  and  Sanitary  Science. 
With  Illustrations.     8th  Edition.  Preparing: 

\yEVL.  Sanitary  Relations  of  the  Coal-Tar  Colors.  Author- 
ized Translation  by  Henry  LeFFMANN,  M.D.,  PH.D.  J1.25 

***  Special  Catalogue  of  Books  on  Hygiene  free  upon  application. 

LUNGS  AND  PLEUR-ffi. 

HARRIS  AND  BEALE.  Treatment  of  Pulmonary  Consump- 
tion. I2.50 

POWELL.  Diseases  of  the  Lungs  and  Pleurae,  including 
Consumption.     Colored  Plates  and  other  lUus.     4th  Ed.  I4.00 

TUSSEY.  High  Altitudes  in  the  Treatment  of  Consumption. 
Just  Ready.  Ji.So 


SUBJECT  CATALOGUE. 


MASSAGE. 

KLEEN.  Hand-Book  of  Massage.  Authorized  translation  by 
MussBY  Hartwell,  M.D.,  PH.D.  With  an  Introduction  by  Dr.  S. 
Weir  Mitchell.  Illustrated  by  a  series  of  Photographs  Made 
Especially  by  Dr.  Kleen  for  the  American  Edition.  ^2.25 

MURRELL.  Massotherapeutics.  Massage  as  a  Mode  of  Treat- 
ment.    6th  Edition.  In  Press. 

OSTROM.  Massage  and  the  Original  Swedish  Move- 
ments. Their  Application  to  Various  Diseases  of  the  Body.  A 
Manual  for  Students,  Nurses,  and  Physicians.  Third  Edition,  En- 
larged.    94  Wood  Engravings,  many  of  which  are  original.  ^i.oo 

WARD.     Notes  on  Massage.     Interleaved.  Paper  cover, gi. 00 

MATERIA    MEDICA    AND     THERA- 
PEUTICS. 

ALLEN,  HARLAN,  HARTE,  VAN  HARLINGEN.  A 
Hand-Book  of  Local  Therapeutics,  Beinga  Practical  Description 
of  all  those  Agents  Used  in  the  Local  Treatment  of  Diseases  of  the 
Eye,  Ear,  Nose  and  Throat,  Mouth,  Skin,  Vagina,  Rectum,  etc., 
such  as  Ointments,  Plasters,  Powders,  Lotions,  Inhalations,  Supposi- 
tories, Bougies,  Tampons,  and  the  Proper  Methods  of  Preparing  and 
Applying  Them.  Cloth,  $3.00  ;  Sheep,  J4.00 

BIDDLE.  Materia  Medica  and  Therapeutics.  Including  Dose 
List,  Dietary  for  the  Sick,  Table  of  Parasites,  and  Memoranda  of 
New  Remedies.  13th  Edition,  Thoroughly  Revised  in  accord- 
ance with  the  new  U.  S.  P.     64  Illustrations  and  a  Clinical  Index. 

Cloth,  J4.00;  Sheep,  J5.00 
BRACKEN.  Outlines  of  Materia  Medica  and  Pharmacology.  J2.75 
DAVIS.  Materia  Medica  and  Prescription  ^A^riting.  I1.50 
FIELD.     Evacuant  Medication.    Cathartics  and  Emetics,      I1.75 

GORQAS.  Dental  Medicine.  A  Manual  of  Materia  Medica  and 
Therapeutics.     6th  Edition,  Revised.    Just  Ready.  ^400 

GROFF.     Materia  Medica  for  Nurses.  In  Press. 

HELLER.      Essentials   of  Materia   Medica,  Pharmacy,  and 

Prescription  Writing.  Ji.oo 

MAYS.    Theine  in  the  Treatment  of  Neuralgia.     %  bound,  .50 

NAPHEYS.  Modern  Therapeutics.  Qth  Revised  Edition,  En- 
larged and  Improved.  In  two  handsome  volumes.  Edited  by  Allen 
J.  Smith,  m.d.,  and  J.  Aubrey  Davis,  m.d. 

Vol.  I.  General  Medicine  and  Diseases  of  Children.  J4.00 

Vol.  II.  General  Surgery,  Obstetrics,  and  Diseases  of  Women.   I4.Q0 

POTTER.  Hand-Book  of  Materia  Medica,  Pharmacy,  and 
Therapeutics,  including  the  Action  of  Medicines,  Special  Therapeu- 
tics, Pharmacology,  etc.,  including  over  600  Prescriptions  and  For- 
mulae. 6th  Edition,  Revised  and  Enlarged.  With  Thumb  Index  in 
each  copy.  Cloth,  J4. 50;  Sheep,  ;gs. 50 

POTTER.  Compend  of  Materia  Medica,  Therapeutics,  and 
Prescription  Writing,  with  Special  Reference  to  the  Physiologi- 
cal Action  of  Drugs.  6tri  Revised  and  Improved  Edition,  based  upon 
the  U.  S.  P.  i8go  .80;  Interleaved,  J1.25 


MEDICAL  BOOKS.  13 


SAYRE.    Organic  Materia  Medica  and  Pharmacognosy.    An 

Introduction  to  the  Study  of  the  Vegetable  Kingdom  and  the  Vege- 
table and  Animal  Drugs.  Comprising  the  Botanical  and  Physical 
Characteristics,  Source,  Constituents,  and  Pharmacopeial  Prepara- 
tions. With  chapters  on  Synthetic  Organic  Remedies,  Insects  In- 
jurious to  Drugs,  and  Pharmacal  Botany.  A  Glossary  and  543  Illus- 
trations, many  of  which  are  original.  I4.00 

■WARING.  Practical  Therapeutics.  4th  Edition,  Revised  and 
Rearranged.  Cloth,  J2.00;  Leather,  J3.00 

WHITE  AND  WILCOX.  Materia  Medica,  Pharmacy,  Phar- 
macology, and  Therapeutics.  3d  American  Edition,  Revised  by 
Rbynold  W.  Wilcox,  m.a.,  m.d.,  ll.d.      Clo.,  J2.75;  Lea.,  ^3.25 


MEDICAL    JURISPRUDENCE     AND 
TOXICOLOGY. 

REESE.  Medical  Jurisprudence  and  Toxicology.  A  Text-Book 
for  Medical  and  Legal  Practitioners  and  Students.  5th  Edition. 
Revised  by  HenrT  Lkffmann,  m.d.       Clo.,j3.oo;  Leather,  I3.50 

"  To  the  student  of  medical  jurisprudence  and  toxicology  it  is  in- 
valuable, as  it  is  concise,  clear,  and  thorough  in  every  respect." — The 
American  Journal  of  the  Medical  Sciences. 

MANN.     Forensic  Medicine  and  Toxicology.     Illus.  $6.50 

MURRELL.      What    to    Do    in    Cases    of   Poisoning.      7th 

Edition,  Enlarged.  Ji.oo 

TANNER.  Memoranda  of  Poisons.  Their  Antidotes  and  Tests. 
7th  Edition.  .75 

MICROSCOPY. 

BEALE.    The  Use  of  the  Microscope  in  Practical  Medicine. 

For  Students  and  Practitioners,with  Full  Directions  for  Examining  the 
Various  Secretions,  etc.,  by  the  Microscope.  4th  Ed.   500  Illus.  $6.50 

BEALE.  How  to  Work  with  the  Microscope.  A  Complete 
Manual  of  Microscopical  Manipulation,  containing  a  Full  Description 
of  many  New  Processes  of  Investigation,  with  Directions  for  Examin- 
ing Objects  Under  the  Highest  Powers,  and  for  Taking  Photographs 
of  Microscopic  Objects.  5th  Edition.  400  Illustrations,  many  of 
them  colored.  J6.50 

CARPENTER.     The  Microscope  and    Its   Revelations.    7th 

Edition.     800  Illustrations  and  many  Lithographs.  $5-5o 

LEE.      The    Microtomist's    Vade    Mecum.      A   Hand-Book  of 

Methods  of  Microscopical  Anatomy.    887  Articles.      4th  Edition, 

Enlarged.    Just  Ready.  tA-°° 

MACDONALD.    Microscopical  Examinations  of  Water  and  Air. 

25  Lithographic  Plates,  Reference  Tables,  etc.     2d  Edition.        J2.50 

REEVES.  Medical  Microscopy,  including  Chapters  on  Bacteri- 
ology, Neoplasms,  Urinary  Examination,  etc.  Numerous  Illus- 
trations, some  of  which  are  printed  in  colors.  ^250 

WETHERED.  Medical  Microscopy.  A  Guide  tojthe  Use  of  the 
Microscope  in  Practical  Medicine.     100  Illustrations.  J2.00 


SUBJECT  CATALOGUE. 


MISCELLANEOUS. 

BLACK.  Micro-Organisms.  The  Formation  of  Poisons.  A 
Biological  Study  of  the  Germ  Theory  of  Disease.  .75 

BURNETT.     Foods  and  Dietaries.     A  Manual  of  Clinical  Diet- 
etics.   2d  Edition.  #1.50 
GOULD.      Borderland    Studies.      Miscellaneous   Addresses  and 
Essays.     lamo.                                                                                           ^2.00 
GOWERS.    The  Dynamics  of  Life.  .75 
HAIG.    Causation  of  Disease  by  Uric  Acid.    A  Contribution  to 
the  Pathology  of  High  Arterial  Tension,  Headache,  Epilepsy,  Gout, 
Rheumatism,  Diabetes,  Bright's  Disease,  etc.     4th  Edition.        J3.00 
HARE.     Mediastinal  Disease.     Illustrated  by  six  Plates.        J2.00 
HEMMETER.     Diseases  of  the  Stomach.    Their  Special  Path- 
ology, Diagnosis,  and  Treatment.     With  Sections  on  Anatomy,  Dieti 
etics.  Surgery,  etc.    Illustrated.                               Clo.J6.oo;  Sh.  J7.00 
HENRY.     A  Practical  Treatise  on  Anemia.          Half  Cloth,  .50 
LEFFMANN.    The  Coal-Tar  Colors.    With  Special  Reference  to 
their  Injurious  Qualities  and  the  Restrictions  of  their  Use.    A  Trans- 
lation of  Thbodore  Weyl's  Monograph.                                          $1-25 
MARSHALL.    History  of  Woman's  Medical  College  of  Penn- 
sylvania.                                                                                        J1.50 
NEW  SYDENHAM  SOCIETY'S  PUBLICATIONS.    Circulars 
upon  application.                                                               Per  Annum,  }8.oo 
TREVES.    Physical  Education  :  Its  Effects,  Methods,  Etc.  .75 
LIZARS.     The  Use  and  Abuse  of  Tobacco.  .40 
PARRISH.     Alcoholic  Inebriety.                                                  |x.oo 
ST.  CLAIR.     Medical  Latin.                                                           Ji.oo 
SCHREINER.     Diet  Lists.     Pads  of  50.  .75 

NERVOUS  DISEASES. 

BEEVOR.  Diseases  of  the  Nervous  System  and  their  Treat- 
ment. 1^2  50 

GORDINIER.  The  Gross  and  Minute  Anatomy  of  the  Cen- 
tral Nervous  System.     With  many  original  Illustrations. 

Preparing. 

GOAVERS.  Manual  of  Diseases  of  the  Nervous  System.  A 
Complete  Text-Book.  2d  Edition,  Revised,  Enlarged,  and  in  many 
parts  Rewritten.  With  many  new  Illustrations.  Two  volumes. 
Vol.  I.  Diseases  of  the  Nerves  and  Spinal  Cord.  Clo.  $3.00 ;  Sh.  J4.00 
Vol.  II.  Diseases  of  the  Brain  and  Cranial  Nerves;  General  and 
Functional  Disease.  Cloth,  J4.00;  Sheep,  Js.co 

GOWERS.    Syphilis  and  the  Nervous  System.  Ji.oo 

GOWERS.  Diagnosis  of  Diseases  of  the  Brain.  2d  Edition. 
Illustrated.  |i.50 

GOWERS.  Clinical  Lectures.  A  New  Volume  of  Essays  on  the 
Diagnosis,  Treatment,  etc.,  of  Diseases  of  the  Nervous  System.  J2.00 

GOWERS.  Epilepsy  and  Other  Chronic  Convulsive  Diseases. 
2d  Edition.  In  Press 

HORSLEY.  The  Brain  and  Spinal  Cord.  The  Structure  and 
Functions  of.     Numerous  Illustrations.  $2.50 

OBERSTEINER.  The  Anatomy  of  the  Central  Nervous  Or- 
gans. A  Guide  to  the  Study  of  their  Structure  in  Health  and  Dis- 
ease.    198  Illustrations.  ^S-So 


MEDICAL  BOOKS.  15 


ORMEROD.     Diseases  of  the  Nervous  System.    66  Wood  En- 
gravings. Ji.oo 
OSLER.     Cerebral  Palsies  of  Children.    A  Clinical  Study.    J2.00 
OSLER.    Chorea  and  Choreiform  Affections.                          $2.00 
PRESTON.     Hysteria  and  Certain  Allied  Conditions.    Their 
Nature  and  Treatment.     Illustrated.    Just  Ready.                         %2..<x> 
WATSON.     Concussions.  An  Experimental  Study  of  Lesions  Aris- 
ing from  Severe  Concussions.                                        Paper  cover^  Ji.oo 
WOOD.    Brain  Work  and  Overwork.  .40 

NURSING. 

special  Catalogue  of  Books  for  Nurses  sent  free  upon  application. 
•BROWN.     Elementary  Physiology  for  Nurses.  .75 

CANFIELD.  Hygiene  of  the  Sick-Room.  A  Book  for  Nurses  and 
Others.  Being  a  Briet  Consideration  of  Asepsis,  Antisepsis,  Disinfec- 
tion, Bacteriology,  Immunity,  Heating  and  Ventilation,  and  Kindred 
Subjects  for  the  Use  of  Nurses  and  Other  Intelligent  Women.     |i.2s 

CULLINGW^ORTH.  A  Manual  of  Nursing,  Medical  and  Sur- 
gical.    3d  Edition  with  Illustrations.  .75 

CULLINGWORTH.  A  Manual  for  Monthly  Nurses.  3d  Ed.  .40 

CUFF.     Lectures  to  Nurses  on  Medicine.     New  Ed.     /«  Pi-ess. 

DOMVILLE.  Manual  for  Nurses  and  Others  Engaged  in  At- 
tending the  Sick.  8th  Edition.  With  Recipes  for  Sick-room  Cook- 
ery, etc.  -75 

FULLERTON.     Obstetric  Nursing.    40  Ills.    4th  Ed.  $1.00 

FULLERTON.  Nursing  in  Abdominal  Surgery  and  Diseases 
of  Women.  Comprising  the  Regular  Course  of  Instruction  at  the 
Training-School  of  the  Women's  Hospital,  Philadelphia.  2d  Edition. 
70  Illustrations.  $1.50 

GROFF.     Materia  Medica  for  Nurses.  In  Press. 

HUMPHREY.  A  Manual  for  Nurses.  Including  General 
Anatomy  and  Physiology,  Management  of  the  Sick  Room,  etc, 
15th  Ed.     Illustrated.  $1.00 

SHAWE.  Notes  for  Visiting  Nurses,  and  all  those  Interested 
in  the  Working  and  Organization  of  District,  Visiting,  or 
Parochial  Nurse  Societies.  With  an  Appendix  Explaining  the 
Organization  and  Working  of  Various  Visiting  and  District  Nurse  So- 
cieties, by  Helen  C.  Jenks,  of  Philadelphia.  Ji.oo 

STARR.  The  Hygiene  of  the  Nursery.  Including  the  General 
Regimen  and  Feeding  of  Infants  and  Children,  and  the  Domestic  Man- 
agement of  the  Ordinary  Emergencies  of  Early  Life,  Massage,  etc.  6th 
Edition.     25  Illustrations.    Just  Ready.  Ji.oo 

TEMPERATURE  AND  CLINICAL  CHARTS.     See  page  6. 

VOSWINKEL.     Surgical  Nursing,     iii  Illustrations.  Ji.oo 

WARD.     Notes  on  Massage.     Interleaved.  Paper  cover,  Ji.oo 

***  Special  Catalogue  of  Books  on  Nursing fre€  upon  application. 

OBSTETRICS. 

BAR.  Antiseptic  Midwifery.  The  Principles  of  Antiseptic  Meth- 
ods Applied  to  Obstetric  Practice.  Authorized  Translation  by 
Henry  D.  Fry,  m.d.  ,  with  an  Appendix  by  the  Author.  Ji.oo 


16  SUBJECT  CATALOGUE. 

CAZEAUX  AND  TARNIER.  Midwifery.  With  Appendix  by 
Mund6.  The  Theory  and  Practice  of  Obstetrics,  including  the  Dis- 
eases of  Pregnancy  and  Parturition,  Obstetrical  Operations,  etc. 
8th  Edition.  Illustrated  by  Chromo- Lithographs,  Lithographs,  and 
other  full-page  Plates,  seven  of  which  are  beautifully  colored,  and 
numerous  Wood  Engravings.  Cloth,  I4.S0  ;  Full  Leather,  J5.50 

DAVIS.  A  Manual  of  Obstetrics.  Being  a  Complete  Manual  for 
Physicians  and  Students.  2d  Edition.  16  Colored  and  other  Plates 
and  134  other  Illustrations.  ^2.00 

JELLETT.     The  Practice  of  Midwifery.     Illustrated.  J1.7S 

LANDIS.  Compend  of  Obstetrics,  sth  Edition,  Revised  by  Wm. 
H.  Wells,  Assistant  Demonstrator  of  Clinical  Obstetrics,  Jefferson 
Medical  College.     With  many  Illustrations,  .80  ;  Interleaved,  $1.25. 

SCHULTZE.     Obstetrical  Diagrams.     Being  a  series  of  20  Col- 
ored Lithograph  Charts,  Imperial  Map  Size,  of  Pregnancy  and  Mid-« 
wifery,  with  accompanying   explanatory  (German)    text   illustrated 
by  Wood  Cuts.     2d  Revised  Edition. 

Price  in  Sheets,  $26.00;  Mounted  on  Rollers,  Muslin  Backs,  J36.00 

STRAHAN.  Extra-Uterine  Pregnancy.  The  Diagnosis  and 
Treatment  of  Extra-Uterine  Pregnancy.  .75 

WINCKEL.  Text-Book  of  Obstetrics,  Including  the  Pathol- 
ogy and  Therapeutics  of  the  Puerperal  State.  Authorized 
Translation  by  J.  Clifton  Edgar,  a.m.,  m.d.  With  nearly  200  Illus- 
trations. Cloth,  $5.00;   Leather,  J6.00 

FULLERTON.    Obstetric  Nursing.     4th  Ed.    Illustrated.    Ji.oo 

SHIBATA.  Obstetrical  Pocket-Phantom  with  Movable  Child 
and  Pelvis.     Letter  Press  and  Illustrations.  $1.00 

PATHOLOGY. 

BARLOW.     General  Pathology.     795  pages.     8vo.  J5.00 

BLACKBURN.  Autopsies.  A  Manual  of  Autopsies  Designed  for 
the  Use  of  Hospitals  for  the  Insane  and  other  Public  Institutions. 
Ten  full-page  Plates  and  other  Illustrations.  Ji-^S 

BLODGETT.  Dental  Pathology.  By  Albert  N.  Blodgbtt, 
M.D.,  late  Professor  of  Pathology  and  Therapeutics,  Boston  Dental 
College.     33  Illustrations.  |i-2S 

COPLIN.  Manual  of  Pathology.  Including  Bacteriology,  Technic 
of  Post-Mortems,  Methods  of  Pathologic  Research,  etc.  265  Illus- 
trations, many  of  which  are  original.      i2mo.  1J3.00 

GILLIAM.     Pathology.  A  Hand-Book  for  Students.  47  IIlus.     .75 

HALL.  Compend  of  General  Pathology  and  Morbid  Anatomy. 
91  very  fine  Illustrations.  .80;   Interleaved,  Ji. 25 

VIRCHOW.  Post-Mortem  Examinations.  A  Description  and 
Explanation  of  the  Method  of  Performing  Them  in  the  Dead  House 
of  the  Berlin  Charity  Hospital,  with  Special  Reference  to  Medico- 
Legal  Practice.     3d  Edition,  with  Additions.  .75 

WHITACRE.  Laboratory  Text-Book  of  Pathology.  With 
121  Illustrations.    Just  Ready.  fi-So 

PHARMACY. 

special  Catalogue  0/  Books  on  Pharmacy  sent  free  upon  application'. 
COBLENTZ.      Manual   of  Pharmacy.      A   New  and   Complete 

Text-Book  by  the  Professor  in  the  New  York  College  of  Pharmacy. 

2d  Edition,  Revised  and  Enlarged.  437  lUus.   Cloth,|3.so;  Sh.,14.50 


MEDICAL  BOOKS.  17 


BEASLEY.  Book  of  3100  Prescriptions.  Collected  from  the 
Practice  of  the  Most  Eminent  Physicians  and  Surgeons — English, 
French,  and  American.  A  Compendious  History  ot  the  Materia 
Medica,  Lists  of  the  Doses  of  all  the  Officinal  and  Established  Pre- 
parations, an  Index  of  Diseases  and  their  Remedies.     7th  Ed.     $2.00 

BEASLEY.  Druggists'  General  Receipt  Book.  Comprising 
a  Copious  Veterinary  Formulary,  Recipes  in  Patent  and  Proprietary 
Medicines,  Druggists'  Nostrums,  etc. ;  Perfumery  and  Cosmetics, 
Beverages,  Dietetic  Articles  and  Condiments,  Trade  Chemicals, 
Scientific  Processes,  and  an  Appendix  of  Useful  Tables.  loth  Edi- 
tion, Revised.  $2.00 

BEASLEY.  Pocket  Formulary.  A  Synopsis  of  the  British  and 
Foreign  Pharmacopoeias.  Comprising  Standard  and  Approved 
Formulae  for  the  Preparations  and  Compounds  Employed  in  Medical 
Practice.     12th  Edition.  Ik  Press. 

i»ROCTOR.  Practical  Pharmacy.  Lectures  on  Practical  Phar- 
macy. With  Wood  Engravings  and  32  Lithographic  Fac-simile 
Prescriptions.  3d  Edition,  Revised,  and  with  Elaborate  Tables  of 
Chemical  Solubilities,  etc.  $300 

ROBINSON.  Latin  Grammar  of  Pharmacy  and  Medicine. 
2d  Edition.     With  elaborate  Vocabularies.  ^i-75 

SAYRE.  Organic  Materia  Medica  and  Pharmacognosy.  An 
Introduction  to  the  Study  of  the  Vegetable  Kinedom  and  the  Vege- 
table and  Animal  Drugs.  Comprising  the  Botanical  and  Physical 
Characteristics,  Source,  Constituents,  and  Pharmacopeia!  Prepar- 
ations. With  Chapters  on  Synthetic  Organic  Remedies,  Insects 
Injurious  to  Drugs,  and  Pharmacal  Botany.  A  Glossary  and  543 
Illustrations,  many  of  which  are  original.     Cloth,  J4.00;  Sheep,  J5.00 

SCOVILLE.  The  Art  of  Compounding.  Second  Edition,  Re- 
vised and  Enlarged.    Just  Ready.  Cloth,  J2.50  ;  Sheep,  $3.50 

STEWART.  Compend  of  Pharmacy.  Based  upon  "  Reming- 
ton's Text-Book  of  Pharmacy."  5th  Edition,  Revised  in  Accord- 
ance with  the  U.  S.  Pharmacopoeia,  1890.  Complete  Tables  of 
Metric  and  English  Weights  and  Measures.     .80;    Interleaved,  J1.25 

UNITED  STATES  PHARMACOPCEIA.  1890.  7th  Decennial 
Revision.  Cloth,  $2.50  (postpaid,  ^2.77);  Sheep,  $3.00  (postpaid, 
J3.27) ;  Interleaved,  $4.00  (postpaid,  $4.50);  Printed  on  one  side  ot 
page  only,  unbound,  I3.50  (postpaid,  $3.90). 

Select  Tables  from  the  U.  S.  P.  (1890).  Being  Nine  of  the  Most 
Important  and  Useful  Tables,  Printed  on  Separate  Sheets.  Care- 
fully put  up  in  patent  envelope.  .25 

POTTER.  Hand-Book  of  Materia  Medica,  Pharmacy,  and 
Therapeutics.    600  Prescriptions  and  Formulae.    6th  Edition. 

Cloth,  $4.50;  Sheep,  $5.50 

*#*  Special  Catalogue  of  Books  on  Pharmacy  free  upon  application. 

PHYSICAL  DIAGNOSIS. 

BROWN.     Medical  Diagnosis.     A  Manual  of  Clinical   Methods. 

4th  Ed.     112  Illnstrations.    Just  Ready.  Cloth,  ^e. 25 

FENWICK.     Medical  Diagnosis.     8th  Edition.     Rewritten  and 

very  much  Enlarged.     135  Illustrations.  Cloth,  J2.50 

TYSON.     Hand-Book  of  Physical  Diagnosis.     For  Studenu  and 

Physicians.     By  the  Professor  of  Clinical  Medicine  in  the  University 

of  Pennsylvania.  Illus.  3d  Ed.,  Improved  and  Enlarged.  In  Press. 
MEMMINGER.    Diagnosis  by  the  Urine.    23  Illus.  Ji.oo 

2 


18  SUBJECT  ICATALOGUB. 

PHYSIOLOGY. 

BRUBAKER.  Compend  of  Physiology,  8th  Edition,  Revised 
and  Enlarged.     Illustrated.  .80;  Interleaved,  ^1.25 

KIRKE.  Physiology.  (14th  Authorized  Edition.  Dark-Red  Cloth.) 
A  Hand-Book  of  Physiology.  14th  Edition,  Revised  and  Enlarged. 
By  Prof.  W.  D  Halliburton,  of  Kings  College,  London.  661 
Illustrations,   some  of    which  are  printed  in  colors. 

Cloth,  J3.00;  Leather,  ^3.25 

LANDOIS.  A  Text-Book  of  Human  Physiology,  Including 
Histology  and  Microscopical  Anatomy,  with  Special  Reference  to 
the  Requirements  of  Practical  Medicine,  sth  American,  translated 
from  the  9th  German  Edition,  with  Additions  by  Wm.  Stirling, 
M.D.,D.sc.    845  Illus.,  many  of  which  are  printed  in  colors.    In  Press. 

STARLING.     Elements  of  Human  Physiology.     100  Ills.    $1.00 

STIRLING.  Outlines  of  Practical  Physiology.  Including 
Chemical  and  Experimental  Physiology,  with  Special  Reference  to 
Practical  Medicine.     3d  Edition.     289  Illustrations.  ^2.00 

TYSON.     Cell  Doctrine.    Its  History  and  Present  State.        $1.50 

YEO.  Manual  of  Physiology.  A  Text-Book  for  Students  of 
Medicine.  By  Gerald  F.  Yko,  m.d.,  f.r.c.s.  6th  Edition.  254 
Illustrations  and  a  Glossary.  Cloth,  J2. 50  ;  Leather,  J3.00 

PRACTICE. 

BEALE.     On  Slight  Ailments;  their  Nature  and  Treatment. 

2d  Edition,  Enlarged  and  Illustrated.  ^1-25 

CHARTERIS.      Practice  of  Medicine.    6th  Edition.  $1.00 

FOAVLER.      Dictionary  of   Practical    Medicine.      By  various 

writers.  An  Encyclopsedia  of  Medicine.  Clo.,$3.oo;  Half  Mor.  J4.00 

HUGHES.    Compend  of  the  Practice  of  Medicine,    sth  Edition, 

Revised  and  Enlarged. 

Part  I.     Continued,  Eruptive,  and  Periodical  Fevers,  Diseases  of  the 
Stomach,   Intestines,  Peritoneum,  Biliary   Passages,  Liver,  Kid- 
neys, etc.,  and  General  Diseases,  etc. 
Part  II.     Diseases  of  the  Respiratory  System,  Circulatory  System, 
and  Nervous  System;  Diseases  of  the  Blood,  etc. 

Price  of  each  part,  .80;  Interleaved,  $1.25 
Physician's   Edition.      In  one  volume,  including  the  above  two 
parts,  a  Section  on  Skin  Diseases,  and  an  Index.     5th  Revised, 
Enlarged  Edition.     568  pp.  Full  Morocco,  Gilt  Edge,  ^2.25 

ROBERTS.  The  Theory  and  Practice  of  Medicine.  The 
Sections  on  Treatment  are  especially  exhaustive.  9th  Edition, 
with  Illustrations.  Cloth,  I4. 50;  Leather,  ^5.50 

TAYLOR.     Practice  of  Medicine.  Cloth,  J2.00;  Sheep,  $2.50 

TYSON.  The  Practice  of  Medicine.  By  James  Tyson,  m.d.. 
Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania. 
A  Complete  Systematic  Text-book  with  Special  Reference  to  Diag- 
nosis and  Treatment.     Illustrated.     8vo. 

Cloth,  ^5.50  ;  Leather,  J6.50  ;  Half  Russia,  $7.50 

PRESCRIPTION  BOOKS. 

BEASLEY.  Book  of  3100  Prescriptions.  Collected  from  the 
Practice  of  the  Most  Eminent  Physicians  and  Surgeons — English, 
French,  and  American.  A  Compendious  History  of  the  Materia, 
Medica,  Lists  of  the  Doses  of  all  Officinal  and  Established  Prepara- 
tions, and  an  Index  of  Diseases  and  their  Remedies.     7th  Ed.    ^3.00 


MEDICAL  BOOKS.  19 


BEASLEY.  Druggists'  General  Receipt  Book.  Comprising 
a  Copious  Veterinary  Formulary,  Recipes  m  Patent  and  Proprie- 
tary Medicines,  Druggists'  Nostrums,  etc.  ;  Perfumery  and  Cos- 
metics, Beverages,  Dietetic  Articles  and  Condiments,  Trade  Chem- 
icals, Scientific  Processes,  and  an  Appendix  of  Useful  Tables, 
loth  Edition,  Revised.  J2.00 

BEASLEY.  Pocket  Formulary.  A  Synopsis  of  the  British  and 
Foreign  Pharmacopoeias.  Comprising  Standard  Formulae  for  the 
various  Preparations  and  Compounds,     nth  Edition.        Cloth,  |2. 00 

PEREIRA.  Prescription  Book.  Containing  Lists  of  Phrases 
and  Abbreviations  Used  in  Prescriptions,  Grammatical  Construction 
of  Prescriptions,  etc.     i6th  Edition.  Cloth,  .75  ;  Tucks,  ^i.oo 

■WYTHE.     Dose  and  Symptom  Book.    Containing  the  Doses  and 

Uses  of  all  the  Principal  Articles  of  the  Materia  Medica.     17th  Ed. 

Cloth,  .75  ;  Leather,  with  Tucks  and  Pocket,  $1.00 

SKIN. 

BULKLEY.    The  Skin  in  Health  and  Disease.    Illustrated.    .40 
CROCKER.     Diseases  of  the  Skin.     Their  Description,  Pathol- 
ogy, Diagnosis,  and  Treatment,  with  Special  Reference  to  the  Skin 
Eruptions  of  Children,   gz  Illus.   zd  Edition.   Cloth,j4.50;  Sh.,  J5.50 
IMPEY.     Leprosy.     37  Plates.     8vo.  J3.50 

SCHAMBERG.  Diseases  of  the  Skin.  Illustrated.  Being  No. 
16  ?  Quiz-Compend?  Series.  Cloth,  .80;  Interleaved,  gi. 25 

VAN  HARLINGEN.  On  Skin  Diseases.  A  Practical  Manual 
of  Diagnosis  and  Treatment,  with  special  reference  to  Differential 
Diagnosis.  3d  Edition,  Revised  and  Enlarged.  With  Formulae 
and   60  Illustrations,  some  of  which  are  printed  in  colors.        $2.75 

SURGERY  AND  SURGICAL  DIS- 
EASES. 

CAIRD  AND  CATHCART.  Surgical  Hand-Book.  5th  Edition, 
Revised.     188  Illustrations.  Full  Red  Morocco,  ^z.50 

DEAVER.  Appendicitis,  Its  Symptoms,  Diagnosis,  Pathol- 
0£y>  Treatment,  and  Complications.  Elaborately  Illustrated 
with  Colored  Plates  and  other  Illustrations.  Cloth,  ^3.50 

DEAVER.  Surgical  Anatomy.  With  200  Illustrations,  Drawn  by  a 
Special  Artist  from  Directions  made  for  the  Purpose.   In  Preparation. 

DULLES.  What  to  Do  First  in  Accidents  and  Poisoning. 
5th  Edition.     New  Illustrations.  Ji.oo 

HACKER.  Antiseptic  Treatment  of  Wounds,  According  to 
the  Method  in  Use  at  Professor  Billroth's  Clinic,  Vienna.  .50 

HAMILTON.  Lectures  on  Tumors,  from  a  Clinical  Stand- 
point.    Third  Edition,  Revised,  with  New  Illustrations.     In  Press. 

HEATH.  Minor  Surgery  and  Bandaging,  loth  Ed.,  Revised 
and  Enlarged.     158  Illustrations,  62  Formulae,  Diet  List,  etc.      $1.25 

HEATH.  Injuries  and  Diseases  of  the  Jaws.  4th  Edition. 
187  Illustrations.  ^4-5° 

HEATH.  Lectures  on  Certain  Diseases  of  the  Jaws.  64  Illus- 
trations. Boards,  .50 

HORWITZ.  Compend  of  Surgery  and  Bandaging,  including 
Minor  Surgery,  Amputations,  Fractures,  Dislocations,  Surgical  Dis- 
eases, and  the  Latest  Antiseptic  Rules,  etc.,  with  Differential  Diagno- 
sis and  Treatment.  5th  Edition,  very  much  Enlarged  and  Rear- 
ranged.   167  Illustrations,  98  Formulae.   Clo.,.8o;  Interleaved,  Ji. 25 


JO  SUBJECT  CATALOGUE. 

JACOBSON.    Operations    of   Surgery.     Over  200  Illustrations. 

Cloth,  J3. 00;  Leather,  ^4.00 

JACOBSON.  Diseases  of  the  Male  Organs  of  Generation. 
88   Illustrations.  ^6.00 

MACREADY.  A  Treatise  on  Ruptures.  24  Full-page  Litho- 
graphed Plates  and  Numerous  Wood  Engravings.  Cloth,  ^6.00 

MAYLARD.   Surgery  of  the  Alimentary  Canal.   134  lllus.  I7.50 

MOULLIN.  Text-Book  of  Surgery.  With  Special  Reference  to 
Treatment.  3d  American  Edition.  Revised  and  edited  by  John  B. 
Hamilton,  m.d.,  ll.d..  Professor  of  the  Principles  of  Surgery  and 
Clinical  Surgery,  Rush  Medical  College,  Chicago.  623  Illustrations, 
over  200  of  which  are  original,  and  many  of  which  are  printed  in 
colors.  Handsome  Cloth,  J6. 00;   Leather,  $7.00 

"  The  aim  to  make  this  valuable  treatise  practical  by  giving  special 

attention  to    questions  of  treatment  has  been  admirably  carried  out. 

Many  a  reader  will  consult  the  work  with  a  feeling  of  satisfaction  that 

his  wants  have  been  understood,  and  that  they  have  been  intelligently 

met." — The  American  Journal  of  Medical  Science. 

ROBERTS.     Fractures  of  the  Radius.    A  Clinical  and   Patho- 
logical Study.     33  Illustrations.  Ji.oo 
SMITH.     Abdominal  Surgery.     Being  a  Systematic  Description  ot 
all  the  Principal  Operations.    224  lUus.  6th  Ed.    2  Vols.  Clo.,  Jio.oo 
SWAIN.     Surgical  Emergencies.     Fifth  Edition.         Cloth,  Ji. 75 
VOSWINKEL.     Surgical  Nursing,     iii  Illustrations.  |i.oo 
WALSHAM.     Manual    of    Practical    Surgery.      5th    Ed.,    Re- 
vised and  Enlarged.     With  380  Engravings.    Clo.,  ^2.00;   Lea.,  ^2.50 
W^ATSON.     On  Amputations  of   the  Extremities    and  Their 
Complications.     250  Illustrations.  %Si° 

THROAT  AND    NOSE   (see  also  Ear). 
COHEN.     The  Throat  and  Voice.     Illustrated.  .40 

HALL.      Diseases    of   the    Nose    and    Throat.    Two    Colored 

Plates  and  59  Illustrations.  $2:50 

HOLLOPETER.     Hay  Fever.  In  Press. 

HUTCHINSON.    The  Nose  and  Throat.     Including  the  Nose, 

Naso-Pharynx,  Pharynx,  and   Larynx.     Illustrated  by    Lithograph 

Plates  and  40  other  Illustrations.     2d  Edition.  In  Press, 

MACKENZIE.  Pharmacopoeia  of  the  London  Hospital  for 
Dis.  of  the  Throat.    5th  Ed.,  Revised  by  Dr.  F.  G.  Harvey.  $1.00 

McBRIDE.  Diseases  of  the  Throat,  Nose,  and  Ear.  A  Clinical 
Manual.    With  colored  lUus.  from  original  drawings.   2d  Ed.       f6.oo 

POTTER.  Speech  and  its  Defects.  Considered  Physiologically, 
Pathologically,  and  Remedially.  Ji.oo 

^A^OAKES.  Post-Nasal  Catarrh  and  Diseases  of  the  Nose 
Causing  Deafness.     26  Illustrations.  fi.oo 

URINE  AND  URINARY  ORGANS. 

ACTON.  The  Functions  and  Disorders  of  the  Reproductive 
Organs  in  Childhood,  Youth,  Adult  Age,  and  Advanced  Life, 
Considered  in  their  Physiological,  Social,  and  Moral  Relations. 
8th  Edition.  $1.75 

ALLEN.    Albuminous  and  Diabetic  Urine.    lUus.  P'-^S 


MEDICAL  BOOKS.  21 

BROCKBANK.    Gall  Stones.  J2.25 

BEALE.     One   Hundred   Urinary   Deposits.     On  eight  sheets, 
for  the  Hospital,  Laboratory,  or  Surgery.  Paper,  J2.00 

HOLLAND.    The  Urine,  the  Gastric  Contents,  the  Common 
Poisons,  and  the  Milk.     Memoranda,  Chemical  and  Microscopi- 
cal, for  Laboratory  Use.    Illustrated  and  Interleaved.    5th  Ed.  Ji.oo 
MEMMINGER.     Diagnosis  by  the  Urine.     23  lUus.  Ji.oo 

MOULLIN.     Enlargement  of  the  Prostate.    Its  Treatment  and 
Radical  Cure.     2d  Edition.     Illustrated.  In  Press. 

THOMPSON.     Diseases  of  the  Urinary  Organs.    8th  Ed.  $3.00 
TYSON.     Guide  to  Examination  of  the  Urine.     For  the  Use  of 
Physicians  and  Students.     With  Colored  Plate  and  Numerous  Illus- 
trations engraved  on  wood.     9th  Edition,  Revised.  $1-25 
VAN   NUYS.    Chemical  Analysis  of  Healthy  and  Diseased 
Urine,  Qualitative  and  Quantitative.    39  Illustrations.       Ji.oo 


VENEREAL  DISEASES. 

COOPER.     Syphilis.    2d    Edition,  Enlarged  and  Illustrated  with 

20  full-page  Plates.  >S-oo 

GOWERS.    Syphilis  and  the  Nervous  System,  i.oo 

JACOBSON.    Diseases  of  the  Male  Organs  of  Generation.    88 

Illustrations.  J6.00 

VETERINARY. 

ARMATAGE.  The  Veterinarian's  Pocket  Remembrancer. 
Being  Concise  Directions  for  the  Treatment  of  Urgent  or  Rare  Cases, 
Embracing  Semeiology,  Diagnosis,  Prognosis,  Surgery,  Treatment, 
etc.    2d  Edition.  Boards,  Ji. 00 

BALLOU.  Veterinary  Anatomy  and  Physiology.  29  Graphic 
Illustrations.  .80;  Interleaved,  Ji. 25 

TUSON.  Veterinary  Pharmacopoeia.  Including  the  Outlines  of 
Materia  Medica  and  Therapeutics.     5th  Edition.  ^2.25 


WOMEN,  DISEASES  OF. 

BYFORD  (H.  T.).  Manual  of  Gynecology.  Second  Edition, 
Revised  and  Enlarged  by  100  pages.  With  341  Illustrations,  many 
of  which  are  from  original  drawings.     Just  Ready.  I300 

BYFORD  (W.  H.).  Diseases  of  Women.  4th  Edition.  306 
Illustrations.  Cloth,  ^2.00 

DUHRSSEN.  A  Manual  of  Gynecological  Practice.  105 
Illustrations.  Ji-SO 

LEWERS.    Diseases  of  Women.    146  lUus.    sth  Ed.  $2.50 

WELLS.  Compend  of  Gynecology.  lUus.  .80;  Interleaved, |i. 25 

FULLERTON,  Nursing  in  Abdominal  Surgery  and  Diseases 
of  'Women.     2d  Edition.    70  Illustrations.  |i'5o 


SUBJECT  CATALOGUE. 


COMPENDS. 


From  The  Southern  Clinic. 

"  We  know  of  no  series  of  books  issued  by  any  house  that  so  fully 
meets  our  approval  as  these  ?  Quiz-CompendsT.  They  are  well  ar- 
ranged, full,  and  concise,  and  are  really  the  best  line  of  text-books  that 
could  be  found  for  either  student  or  practitioner." 


BLAKISTON'S  ?QUIZ-COMPENDS? 

The  Best  Series  of  Manuals  for  the  TJse  of  Students. 
Price  of  each,  Cloth,  .80.         Interleaved,  for  taking  Notes,  $1.25. 

fl^  These  Corapends  are  based  on  the  most  popular  text-books 
and  the  lectures  of  prominent  professors,  and  are  kept  constantly  re- 
vised, so  that  they  may  thoroughly  represent  the  present  state  of  the 
subjects  upon  which  they  treat. 

4®"  The  authors  have  had  large  experience  as  Quiz-Masters  and 
attaches  of  colleges,  and  are  well  acquainted  with  the  wants  of  students. 

j8®~  They  are  arranged  in  the  most  approved  form,  thorough  and 
concise,  containing  over  6oo  fine  illustrations,  inserted  wherever  they 
could  be  used  to  advantage. 

>9^  Can  be  used  by  students  ot  any  college. 

>9^  They  contain  information  nowhere  else  collected  in  such  a 
condensed,  practical  shape.     Illustrated  Circular  free. 

No.  I.  POTTER.  HUMAN  ANATOMY.  Fifth  Revised  and 
Enlarged  Edition.  Including  Visceral  Anatomy.  Can  be  used 
with  either  Morris's  or  Gray's  Anatomy.  117  Illustrations  and  16 
Lithographic  Plates  of  Nerves  and  Arteries,  with  Explanatory 
Tables,  etc.  By  Samuel  O.  L.  Potter,  m.d.,  Professor  of  the 
Practice  of  Medicine,  Cooper  Medical  College,  San  Francisco  ;  late 
A.  A.  Surgeon,  U.  S.  Army. 

No.  2.  HUGHES.  PRACTICE  OF  MEDICINE.  Part  I.  Fifth 
Edition,  Enlarged  and  Improved.  By  Daniel  E.  Hughes,  m.d., 
Physician-in-Chief,  Philadelphia  Hospital,  late  Demonstrator  ot 
Clinical  Medicine,  JeflFerson  Medical  College,  Phila. 

No.  3.  HUGHES.  PRACTICE  OF  MEDICINE.  Part  II. 
Fifth  Edition,  Revised  and  Improved.     Same  author  as  No.  2. 

No.  4.  BRUBAKER.  PHYSIOLOGY.  Eighth  Edition  with 
new  Illustrations  and  a  table  of  Physiological  Constants.  Enlarged 
and  Revised.  By  A.  P.  Brubaker,  m.d..  Professor  of  Physiology 
and  General  Pathology  in  the  Pennsylvania  College  of  Dental 
Surgery  ;  Demonstrator  of  Physiology,  Jefferson  Medical  College, 
Philadelphia. 

No.  5.  LANDIS.  OBSTETRICS.  Fifth  Edition.  By  Henry  G. 
Landis,  m.d.  Revised  and  Edited  by  Wm.  H.  Wells,  m.d., 
Assistant  Demonstrator  of  Obstetrics,  Jefferson  Medical  College, 
Philadelphia.     Enlarged.     47  Illustrations. 

No.  6.  POTTER.  MATERIA  MEDICA,  THERAPEUTICS, 
AND  PRESCRIPTION  WRITING.  Sixth  Revised  Edition 
(U.  S.  P.  1890).  By  Samuel  O.  L.  Potter,  m.d.,  Professor  of 
Practice,  Cooper  Medical  College,  San  Francisco  ;  late  A.  A.  Sur- 
geon, U.  S.  Army. 


MEDICAL  BOOKS. 


PQUIZ-COMPENDS  ?— Continued. 

No,  7.  WELLS.  GYNECOLOGY.  A  New  Book.  By  Wm. 
H.  Wells,  M.D.,  Assistant  Demonstrator  of  Obstetrics,  Jefferson 
College,  Philadelphia.     150  Illustrations. 

No.  8.  GOULD  AND  PYLE.  DISEASES  OF  THE  EYE 
AND  REFRACTION.  A  New  Book.  Including  Treatment 
and  Surgery,  and  a  Section  on  Local  Therapeutics.  By  George 
M.  Gould,  m.d.,  and  W.  L.  Pylh,  m.d.  With  Formulae,  Glossary, 
Tables,  and  iii  Illustrations,  several  of  which  are  Colored. 

No.  9.  HOR"WITZ.  SURGERY,  Minor  Surgery,  and  Bandag- 
ing. Fifth  Edition,  Enlarged  and  Improved.  By  Grvillb 
HoRWiTZ,  B.  S-,  M.D.,  Clinical  Professor  of  Genito-Urinary  Surgery 
and  Venereal  Diseases  in  Jefferson  Medical  College  ;  Surgeon  to 
Philadelphia  Hospital,  etc.    With  98  Formulae  and  71  Illustrations. 

No.  10.  LEFFMANN.  MEDICAL  CHEMISTRY.  Fourth 
Edition.  Including  Urinalysis,  Animal  Chemistry,  Chemistry  of 
Milk,  Blood,  Tissues,  the  Secretions,  etc.  By  Henry  Leffmann, 
M.D.,  Professor  of  Chemistry  in  Pennsylvania  College  of  Dental 
Surgery  and  in  the  Woman's  Medical  College,  Philadelphia. 

No.  II.  STEWART.  PHARMACY.  Fifth  Edition.  Based  upon 
Prof  Remington's  Text-Book  of  Pharmacy.  By  F.  E.  Stewart, 
M.D.,  PH.G.,  late  Quiz-Master  in  Pharmacy  and  Chemistry,  Phila- 
delphia College  of  Pharmacy ;  Lecturer  at  Jefferson  Medical 
College.     Carefully  revised  in  accordance  with  the  new  U.  S.  P. 

No.  12.  BALLOU.  VETERINARY  ANATOMY  AND  PHY- 
SIOLOGY. Illustrated.  By  Wm.  R.  Ballou,  m.d..  Professor 
of  Equine  Anatomy  at  New  York  College  of  Veterinary  Surgeons  ; 
Physician  to  Bellevue  Dispensary,  etc.     29  graphic  Illustrations. 

No.  13.  ^VARREN.  DENTAL  PATHOLOGY  AND  DEN- 
TAL MEDICINE.  Third  Edition,  Illustrated.  Containing 
a  Section  on  Emergencies.  By  Geo.  W.  Warren,  d.d.s..  Chief 
of  Clinical  Staff,  Pennsylvania  College  of  Dental  Surgery. 

No.  14.  HATFIELD,  DISEASES  OF  CHILDREN.  Second 
Edition.  Colored  Plate.  By  Marcus  P.  Hatfield,  Profes- 
sor of  Diseases  of  Children,  Chicago  Medical  College. 

No.  15.  HALL.  GENERAL  PATHOLOGY  AND  MORBID 
ANATOMY.  91  Illustrations.  By  H.  Newberry  Hall,  ph. g., 
M.D.,  late  Professor  of  Pathology,  Chicago  Post-Graduate  Medi- 
cal School. 

No.  16.  DISEASES  OF  THE  SKIN.  By  Jay  T.  Schamberg, 
M.D.,  Instructor  in  Skin  Diseases,  Philadelphia  Polyclinic.  With 
many  Viandsome  Illustrations. 

Price,  each,  Cloth,  .80.  Interleaved,  for  taking  Notes,  $1,25. 

In  preparing,  revising,  and  improving  Blakiston's  ?  Quiz-Com- 
pends  ?  the  particular  wants  of  the  student  have  always  been  kept  in 
mind. 

Careful  attention  has  been  given  to  the  construction  of  each  sentence, 
and  while  the  books  will  be  found  to  contain  an  immense  amount  of 
knowledge  in  small  space,  they  will  likewise  be  found  easy  reading ; 
there  is  no  stilted  repetition  of  words  ;  the  style  is  clear,  lucid,  and  dis- 
tinct. The  arrangement  of  subjects  is  systematic  and  thorough  ;  there 
is  a  reason  for  every  word.    They  contain  over  600  illustrations. 


Tyson's 
Practice  of 
Medicine. 


With  Many 
Illustrations. 


Text-Book  of  the  Practice  of  Medi- 
cine. With  Special  Reference  to  Diagnosis 
and  Treatment.  By  James  Tyson,  m.  d., 
Professor  of  Clinical  Medicine  in  the  Univer- 
sity of  Pennsylvania;  Physician  to  the  Hos- 
pital of  the  University  and  to  the  Philadelphia 
Hospital ;  Fellow  of  the  College  of  Physicians 
of  Philadelphia,  etc. 


With  Many  Useful  Illustrations. 

Octavo.      1 1 80  Pages. 

Cloth,  $5.50;  Sheep,  $6.50;  Half  Russia,  $7.50. 


Extracts  from  a  Review  in  the  American  Journal  of 
Medical  Sciences,  March,  1897: 

"  Externally  it  is  the  largest  and  handsomest  single  volume 
on  the  practice  of  medicine." 

"Clinical  features  are  usually  described  in  a  masterly  way." 

"The  directions  (for  treatment)  are  full  and  clear,  and  as 
a  rule,  eminently  judicious  and  conservative." 

"  Dr.  Tyson's  style  is  already  so  well  known  in  medical 
literature  that  it  is  only  necessary  to  say  the  present  work  is 
one  of  the  best  examples." 

"We  welcome  Dr.  Tyson's  Practice  as  a  most  valuable 
addition  to  medical  literature." 

^Descriptive  circular  and  sample  pages  upon  application. 


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Surgery,  Its  theory  and  practice  / 


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